V^CL£,Ogj 


USI 


Columbia  ilnitJCi^ttp 

intljrCitpofilftngork 

College  of  |3f)Pgicians(  anb  ^urgeong 
Uifararp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatmentofgonorOOIeed 


THE    TREATMENT    OF    GONORRHCEA 
IN    THE    MALE 


BY  THE  SAME  AUTHOR. 
ON 

THE  STERILIZATION  OF  THE  HANDS 

B  JCnctcriolOi'iicnl  5iuiuir\:  into  the  TRclnttvc  Unluc 

ot  Uaiioik'  iUicnti?  lli?c^  in  tbc  Bis3infcction 

of  tbc  IbanDs 

Cloth.     Price  2s.  6d. 

'  Mr.  C.  I.cedham-Grecn's  treatise  "On  the  Sterilization  of  the  Hands"  is 
the  outcome  of  researches  on  this  important  subject  which  have  extended 
over  several  years.  It  is  not  only  an  account  of  these  researches  hut  a  com- 
prehensive critical  review  of  the  investigations  of  other  surgeons  on  the 
same  question.  It  is  to  be  welcomed  as  a  valuable  contribution  to  the  dis- 
cussion of  skin  sterili/atioii.' — The  llritisli  Muliml  Journal. 

'  In  this  little  book  Mr.  Leedham-Cireeii  records  the  results  of  investigations 
made  by  him  on  the  relative  values  of  difl'erent  methods  of  disinfecting  the 
skin.  They  represent  the  work  of  many  years,  and  form  a  valuable  contribu- 
tion to  the  literature  of  this  important  subject.  He  selected  the  methods 
which  have  been  advocated  in  this  country  as  well  as  on  the  Continent,  and 
subjected  each  to  a  uniform  and  severe  practical  test.  The  experiments  have 
been  carried  out  with  untiring  energy  and  ingenuity,  and  the  excellence  of 
the  bacteriological  techniiiue  renders  the  work  of  great  interest  and  value. 
It  should  achieve  good  practical  results.' — Tlu  Scottish  Mctluitl  and  Siiifikal 
Jotunal. 

'  Mr.  Leedham-Green"s  work  has  been  done  so  carefully,  so  thoroughly, 
and  with  such  an  obvious  absence  of  preconceived  ideas,  that  his  book,  which 
is  a  concise  and  readable  record  of  his  work,  must  be  taken  to  emboily  the 
opinions  of  an  authority  on  the  subject.  It  is  a  book  which  should  be  read 
by  everyone  engaged  in  the  practice  of  operative  surgery  or  of  midwifery." — 
Tlie  liiniiiiijiliam  Medical  Rd'iai: 

'There  are  several  matters  of  much  practical  importance  dealt  with  in  this 
book,  in  addition  to  the  record  of  experiments;  in  particular  must  be  noted 
the  section  of  the  duration  of  the  sterility  of  a  disinfected  hand  and  on  time 
as  a  factor  in  diminishing  the  inl'cctivity  of  the  hands.  Mr.  Leedham-tlreen's 
work  has  extended  over  a  considerable  number  of  years  ;  it  is  a  work  which 
has  called  for  much  patience,  but  it  is  well  worth  all  the  time  he  has  .spent  on 
it,  and  deserves  the  thanks  of  all  operating  surgeons.'— 7Vi<  Hritisli  Jotiitial 
cl  Cliildirn's  IJiscasis. 

'  We  put  a  high  value  on  the  researches  recorded  in  this  book,  and  feel  sure 
that  a  close  adherence  lo  the  principles  laid  down  will  go  far  to  minimize  the 
risk  of  the  surgeon  or  his  assistants  infecting  a  wound.' — Tlic  Lancet. 

'  This  book  should  be  carefully  read  by  every  surgeon  :  it  is  the  best  ex- 
position we  have  >een  on  the  subject  of  hand  steriliz-ttion.  Mr.  Leedham- 
Green  has  approached  the  ni.tter  quite  impartially,  and  although  the  nine 
pages  of  bibliography  at  the  end  of  the  book  show  that  he  has  sojourned  long 
in  the  inazesof  medical  literature,  his  conclu-sions are  founded  solely  on  ocular 
testimony  derived  from  thorough  experimental  inquiry.  .  .  .  We  gladly 
commend  the  book  to  the  notice  of  the  medical  profession.'— r/zt-  Haplal. 


THE  TREATMENT  OF 
GONORRHOEA  IN  THE  MALE 


BY 


CPIARLES  LEEDHAM-GREEN,  M.B.,  F.R.C.S. 

SENIOR   SURGEON    TO   OUT-PATIENTS,    QUEEn's    HOSPITAL,    BIRMINGHAM 

SURGEON     TO     THE     BIRMINGHAM      AND     MIDLAND     HOSPITAL     FOR     CHILDREN 

ASSISTANT    LECTURER   ON    BACTERIOLOGY,    UNIVERSITY   OF    BIRMINGHAM 


NEW    YORK 
WILLIAM     WOOD     &     COMPANY 

IMDCCCCVI 


KC 


4o 


PREFACE 

During  the  past  few  years  a  considerable  advance  has 
been  made  in  our  knowledge  of  gonorrhoea,  and  con- 
sequently in  our  methods  of  treating  it.  On  the  Con- 
tinent several  important  monographs  dealing  with  this 
subject  have  recently  been  published,  but  some  years  have 
passed  since  one  appeared  in  England.  I  have  therefore 
in  the  following  pages  endeavoured  to  give  a  concise  yet 
detailed  account  of  the  modern  views  of  the  pathology 
and  treatment  of  this  disease,  with  a  view  to  assisting 
students  and  practitioners  to  whom  the  foreign  literature 
and  our  own  scattered  papers  on  the  subject  are  difficult 
of  access.  I  have  included  several  chapters  dealing  with 
the  chief  complications  of  the  disease.  It  seemed  in- 
advisable to  attempt  to  speak  here  either  of  stricture  or 
of  gonorrhceal  conjunctivitis.  The  former  is  too  exten- 
sive a  subject  to  be  adequately  discussed  in  the  space 
available,  and  the  latter  belongs  more  correctly  to  the 
domain  of  the  ophthalmic  surgeon. 

Apart  from  the  references  in  the  text,  I  wish  to  acknow- 


vi  Preface 

ledge  my  indebtedness  to  the  recent  writinj^s  of  Guyon, 
Jadassohn,  Kollmann,  Obcrlaiidcr,  Wossitllo,  von  Zeiss), 
and  especially  to  the  teachings  and  works  of  Professor 
Finger,  of  Vienna,  and  Dr.  Casper,  of  Berlin. 

CHAS.  LEEDHAM-GREEN. 

lURMl^on.\M,y(i/iU(irj%  1906. 


CONTENTS 


PAfiE 

PREFACE  ------  V 


PART  I. 
CHAPTER  I 


INTRODUCTION 


CHAPTER  II 

SOME    IMPORTANT   DETAILS    CONCERNING    THE    ANATOMY    OF 

THE    URETHRA   AND    BLADDER   -  -  -  -  3 

CHAPTER  III 

ACUTE    URETHRITIS  -  -  -  -  "  ^5 

CHAPTER  IV 

ACUTE    POSTERIOR    URETHRITIS  -  -  -  "  ^9 

CHAPTER  V 

THE    BACTERIOLOGICAL    DIAGNOSIS    OF    GONORRHCEA  -         27 

CHAPTER  VI 

THE    MORBID    CHANGES    IN    THE    URETHRAL    SECRETION    AND 

MUCOUS    MEMBRANE        -  -  -  -  "34 

vii 


viii  Contents 

CHAITHR  \1I 

THE    TKHAlMKN'l-    oK    ACUTE    URETHRITIS      -  4^ 

ClIAriKK   \11I 
IHE    IRKATMEXT   OF    ACUTE    ANTERIOR    URETHRITIS  -         49 

CHAPTKR   IX 

THE   TREATMENT   OF    ACUTE    POSTERIOR    URETHRITIS  -         56 

CHAPTER  X 

CHRONIC    ITRETHRITIS  -  -  -  -  -  66 

CHAPTER  XI 

THE    DIAGNOSIS    OF   CHRONIC    URETHRITIS      -  -  "74 

CHAPTER  XII 

THE    TREATMENT    OF    CHRONIC    I'RETHRITIS  -  -  -  89 


PART     II. 

THE  COMPLICATIONS  OF  GONORRHCEA 
CHAPTER  I 

15ALANITIS,  PARA-URETHRAL  CANALS,  PAPILLOMATA,  PERI- 
URETHRAL INFLAMMATION,  INFLAMMATION  OFCOWPER's 
GLAND,    LVMr'HAXGITIS    AND    LYMPHADENITIS     -  -  99 

CHAPTER  II 

EPIDIDYMITIS  ....--       107 


Contents  ix 

CllAl'TER  111 

PROSTATITIS  -  -  -  -  -  -       114 

chai'T]':r  IV 

SPERMATO-CVSTITIS   -  -  -  -  -  -       122 


CHAPTER  V 

CYSTITIS  -  .  .  . 

CHAPTER  VI 

PYELITIS    AND    PYELONEPHRITIS 


125 


130 


CHAPTER  VII 

GONORRHCEA    RECTALIS STOMATITIS    AND    RHINITIS  -       1 33 

CHAPTER  VIII 

GONORRHCEAL    METASTASES  -  -  -  -  "       I36 


PART  III. 

THE    PROOF    OF    THE   CURE    OF    GONORRHCEA  :    ITS    BEARING 

ON    MARRIAGE    ------       1^1 


LIST    OF    ILLUSTRATIONS 


1.  Cast  of  Urethra             ......  ^ 

2.  Diagrammatic  Sketch  of  Urethra  and  Hladdcr            -             -  5 

3.  Shape  of  Bladder,  according  to  Finger,  when  it  contains  Ijlu 

little  Fluid                 ....._  7 

4.  Shape  of  Bladder  when  fully  Distended          -             -             -  8 

5.  Radiograph  of  a  fully-distended  Bladder        -             -             -  i  i 

6.  Acute  Gonorrhoeal  Pus  -  -  -  -  -29 

7.  Diagrammatic  Representation  of  the   Multiplication   of  the 

Gonococcus  -             -             -             -             -             -             -  30 

8.  Urethral  Secretion  in  the  Earliest  Stage  of  Acute  Gonorrhcea  36 

9.  Small  Urethral  Syringe             -             -             -             -              -  52 

10.  The  Ockart  Urethral  Syringe               -             -             -             -  54 

11.  Valentine's  Urethral  Irrigator              -             -             -             -  60 

12.  Guyon's  Instillation  Syringe    -  -  -  -  "63 

13.  Ultzmann's  Syringe      -             -             -             -             -             -  63 

14.  Chronic  Gonorrhoeal  Pus^  showing  Secondary  Infection  with 

a  Short,  Slender  Bacillus     -  -  -  -  -77 

15.  Feleki's  Instrument  for  Massage  of  Prostate  -             -             -  78 

16.  Acorn-headed  Black  Gum  Bougie       -             -             -             -  79 

17.  Otis's  Urethrometer     -             -             -             -             -             -  80 

18.  Weir's  Urethrometer    -            -            -             -             -             -  So 

19.  Kollmann's  Urethrometer        -            -            -             -             -  80 

20.  Simple  Endoscope        -             -             -            -             -             -  82 

21.  Schall's  Endoscope      -             -             -             -             -             -  82 

22.  Valentine's  Endoscope              -             -             -             -             -  83  ■ 

23.  Membranous   Portion  of  Normal  Urethra  as  seen  through 

the    Endoscope,    showing   Small    Round    Central  Figure 

with  Numerous  Fine  Radiating  Folds         -             -             -  84 

24.  Normal  Prostatic  Urethra,  showing  the  Anterior  Portion  of 

the  Caput     -             -             -             -             -             -             -  84 


xii  List  of  Illustrations 

FIti. 

25.  Normal  I'rosialic  I'leihra,  showing  llic  Caput  (iallinaginis 

26.  Normal    Urethra    in    the    MicUlle  <jf   the    lUilljous   Portion 

Central  Figure  \'ertical        .  -  -  . 

27.  Endoscopic  Appearance  of  I'hrunically-Intlamecl  Urethra 

28.  Large  Urethral  Syringe  .... 

29.  Urethra!  Ointment  Introducer 

30.  Obcrliinders  Urethral  Dilator 
3^  32)  33-  KoUmann's  Urethral  Dilators  - 

34.  Neisser's  Suspensory  Bandage 

35.  Sperm  Crystals  .  .  -  .  . 

36.  IVcthral  Thread  in  Chronic  Urethritis 


«5 

85 
87 
91 
92 

95 

95 

1 12 

iiS 

14+ 


PART  I. 

CHAPTER  I 
INTRODUCTION 

The  term  '  gonorrhoea  '  is  a  ridiculous  misnomer  in  the 
Hght  of  its  derivation  from  r^ovo'^,  '  the  semen,'  and  pew,  '  I 
flow  ';  yet  the  word  is  so  universally  adopted  that  it  would 
be  a  useless  and  thankless  task  to  suggest  a  more  scientific 
name  for  this  disease. 

In  the  earliest  records  of  prevalent  diseases  we  find  the 
disorder  described  with  singular  clearness  and  exactness. 
Greek,  Roman,  and  Arabian  physicians  frequently  refer  to 
it  in  their  writings  ;  and  we  have  evidence  from  the  Book 
of  Leviticus  that  the  Jews  at  an  early  period  clearly  under- 
stood its  nature  and  contagious  character.  In  the  Middle 
Ages  its  infectious  nature  was  so  well  recognised  that  in 
many  towns,  both  in  England  and  on  the  continent  of 
Europe,  regulations  were  in  force  compelling  the  periodical 
medical  examination  of  public  prostitutes  for  '  the  perilous 
infirmity  of  burning.' 

Towards  the  end  of  the  fifteenth  centur}',  when  a  great 
epidemic  of  syphilis  spread  over  Europe,  gonorrhoea,  if 
not  entirely  lost  sight  of,  was  so  overshadowed  by  the 
more  serious  venereal  disorder  that  for  a  long  time  after- 
wards the  two  diseases  were  regarded  and  treated  as 
identical.     Indeed,  it  was  not  until  the  beginning  of  the 

I 


2         Treatment  of  Gonorrhoea  in  the  Male 

eighteenth  ccntur)-  that  the  distinction  between  them  was 
indisputably  demonstrated  and  accepted  by  the  medical 
profession.  But  long  after  this  gonorrhoea  was  generally 
regarded  as  an  inflammation,  which  might  be  occasioned 
by  a  variety  of  causes  besides  infection.  Excessive  bodily 
fatigue,  indulgence  in  alcohol,  as  well  as  contact  with 
menstrual  and  other  discharges,  were  deemed  capable  of 
causing  it. 

These  views,  however,  gradually  gave  place  to  more 
correct  ones  as  to  the  nature  of  the  disease,  so  that  by 
the  middle  of  the  nineteenth  century  its  specific  origin 
was  generall}'  recognised. 

It  was  in  1S79  that  Neisser  first  published  a  description 
of  a  coccus  which  was  invariably  present  in  all  fresh  cases 
of  gonorrhoea,  and  to  which  he  gave  the  name  of  gono- 
coccus.  A  few  years  later  Bumm  first  succeeded  in 
cultivating  the  micro-organism  on  coagulated  blood- 
serum,  and  in  transmitting  the  disorder  by  inoculation 
to  a  healthy  urethra  with  a  pure  culture  of  the  coccus. 
These  discoveries  have  been  the  basis  of  all  subsequent 
treatment  of  the  disease. 


CHAPTER  II 

SOME     IMPORTANT     DETAILS     CONCERNING     THE 
ANATOMY  OF  THE  URETHRA  AND  BLADDER 

Before  proceeding  to  deal  with  the  nature  and  treatment 
of  urethritis,  it  is  necessary  to  draw  attention  to  the 
following  anatomical  details,  which  are  of  great  practical 
importance  to  the  surgeon,  and  which  are  not  adequately 
discussed  in  the  text-books  on  anatomy. 

1 .  The  Lumen  of  the  Urethra. 

In  the  resting  state  there  is  no  true  lumen  to  the 
urethra,  for  the  walls  are  in  contact,  and  are  onh- 
separated  so  as  to  form  a  canal  during  the  flow  of  urine 
and  semen,  or  the  passage  of  a  surgical  instrument. 

The  diameter  of  the  lumen,  or,  more  correctly,  the 
extent  to  which  the  canal  may  be  dilated,  varies  greatly 
in  its  different  parts.  The  relative  dilatability  of  the 
various  portions  is  clearly  shown  in  Fig.  i,  which  is 
drawn  from  a  cast  of  the  urethra  taken  in  fusible  metal 
immediately  after  death.  The  prostatic  and  bulbous 
parts  are  the  most  dilatable,  then  the  penile  and  mem- 
branous. The  meatus  is  not  only  the  narrowest,  but  bv 
far  the  most  resistant.  As  will  be  seen  later  on,  it  is 
important  to  know  precisely  to  what  extent  the  several 

3  1—2 


Treatment  of  Gonorrhoea  in  the  Male 


Fig.  I. 


A,  Fossa  navicularis  ;  B,  penile  portion  ;  C,  bulbous  portion  ; 
D,  membranous  portion;   E,  prostatic  portion. 

portions  of  the  normal   urethra  can  be  dilated.     This  is 
indicated  in  the  following  table  : 


The  meatus 
Middle  of  penile     ... 
Bulbous  portion 
Membranous  portion 
Prostatic  portion    ... 


French  Scale.* 

7  to    8  mm.  in  diametcr=No.  21  to  24 

10  „  „         =No.  30 

13  to  15       „  „         =No.  391045. 

9  to  10       „  „         =No.  27  to  30. 

13  to  15       „  „         =No.  391045. 


*  I.c.y  will  admit  a  urethral  instrument  of  this  size.    See  p.  80. 


Anatomy  of  the  Urethra  and  Bladder         5 


2.  The  Muscular  Fibres  of  the  Urethra  and  Bladder. 

Although  it  is  convenient  anatomically  to  divide  the 
urethra  into  the  several  portions  mentioned  above 
(prostatic,  membranous,  bulbous,  and  pcnilcj,  in  practice 


Fig.  2. — Diagrammatic  Sketch  of  Urethra  and  Bladder. 

I,  Bladder;  2,  prostate  gland;  3,  internal  vesical  or  prostatic  sphincter; 
4,  external  vesical  or  prostatic  sphincter  ;  5,  ejaculatory  duct  ;  6, 
seminal  vesicle  ;  7,  compressor  urethra2  muscle  surrounding  mem- 
branous urethra;  8,  bulb  of  the  corpus  spongiosum;  9,  corpus 
cavernosum  ;  10,  glans  penis  ;  11,  fossa  navicularis  ;  12,  sphincter  ani. 

the  canal  may  be  advantageously  divided  into  two 
portions,  the  anterior  and  posterior.  This  is  no  arbitrary 
division,  but  founded  upon  anatomical  and  ph3'siological 


6         Treatment  of  Gonorrhoea  in  the  Male 

reasons.  The  anterior  portion  comprises  the  penile  and 
bulbous  parts  ;  the  posterior  the  membranous  and  pro- 
static. Whilst  the  anterior  portion  is  surrounded  by 
erectile  tissue,  the  posterior  is  enveloped  by  muscular 
fibres.  Of  these  muscular  fibres  it  is  necessary  to  say  a 
few  words.  Situated  within  the  prostate  and  surrounding 
the  vesical  orifice  there  is  an  ill-detined  ring  of  involuntary 
muscular  fibres,  intermixed  with  much  elastic  tissue. 
This  ring  is  called  the  internal  prostatic  or  vesical 
sphincter.  The  fibres  of  this  muscle  are  so  slender  that 
it  is  believed  by  many  authorities,  including  Finger,  that 
its  action  can  be  but  slight,  and  that  it  is  therefore  not 
sufficiently  powerful  to  prevent  the  escape  of  the  urine 
from  the  distended  bladder.  Within  the  prostate,  below 
the  internal  prostatic  sphincter,  and  separated  from  it  by 
glandular  tissue,  there  is  another  and  more  powerful  ring 
of  muscular  fibres  which  surrounds  the  urethral  canal. 
These  fibres,  chiefly  of  voluntary  muscle,  form  the  external 
prostatic  or  vesical  sphincter.  When  the  urethral  canal 
leaves  the  apex  of  the  prostate,  it  is  still  surrounded  by  a 
thick  layer  of  voluntary  muscular  fibres,  \\hich  is  known 
as  the  compressor  urethras. 

Thus  both  portions  of  the  posterior  urethra  are  sur- 
rounded by  muscular  tissue. 

The  muscular  fibres  in  the  prostatic  and  membranous 
portions  are  usually  in  a  state  of  tonic  contraction,  which 
contraction  can  be  markedly  increased  by  an  exercise  of 
the  will,  but  during  the  act  of  micturition  is  involuntarily 
relaxed. 

According  to  Finger,*  the  bladder  itself  has  no  true 
sphincter  of  its  own  ;  it  is  therefore  unable  to  prevent  the 
escape  of  urine.  This  is  accomplished  by  the  action  of 
the  muscular   fibres    surrounding   the   posterior    urethral 

*  '  Die  IMennorrhoe  Sexualorgane,'  1905,  S.  38. 


Anatomy  of  the  Urethra  and  Bladder 


7 


canal.  When  the  bladder  contains  Ijiit  little  lliiid,  it 
forms  a  round  ball-like  structure,  sharply  defined  from 
the  prostate  by  the  contracted  internal  prostatic  sphincter 
(see  Fig.  3).  And  it  is  not  until  the  bladder  has  become 
distended  that  the  pressure  of  urine  causes  the  elasticity 
of   the   neck  of  the    bladder    and  the    intcrn;i]    prostatic 


Fig.  3. 

A,  Internal  vesical  sphincter  ;  B,  external  vesical  sphincter  ;  C,  com- 
pressor urethrae. 

sphincter  to  yield,  thus  allowing  the  fluid  to  enter  the 
posterior  portion  of  the  prostatic  urethra.  When  this 
takes  place,  the  sharply-defined  border  between  bladder 
and  urethra  is  lost,  and  a  '  bladder-neck  '  is  formed  (see 

Fig.  4)- 

When  the  first  drop  of  urine  enters  the  prostatic  urethra 


8         Treatment  of  Gonorrhoea  in  the  Male 

the  desiie  to  micturate  is  felt.  This  desire  is  provoked  by 
the  irritation  of  the  mucous  membrane  of  the  prostatic 
urethra  by  the  urine.    By  bringinc:  into  phiy  the  vohmtary 


Fig.  4. 
A,  Internal  vesical  sphincter;  B,  external  vesical  sphincter  ;  C,  com- 
pressor urethra:. 

muscles  of  the  posterior  urethra  the  escape  of  urine  can,  if 
desired,  be  prevented. 

The  further  collection  of  urine  takes  place  not  only  in 


Anatomy  of  the  Urethra  and  Bladder         9 

the  distended  bladder,  hut  alsrj  in  iIk;  now  cncroriciied 
upon  prostatic  urethra.  Tliron^'h  this  encroachment  on 
the  prostatic  urethra  by  the  bladder  the  uretJira  is  ap- 
preciably shortened.  This,  Finger  asserts,  can  readily  be 
determined  by  passing  a  catheter  along  the  urethra  until 
the  urine  begins  to  ilow,  and  noting  iiow  far  the  catheter 
has  been  introduced.  When  the  bladder  is  moderately 
full,  but  no  desire  to  micturate  is  present,  the  catheter 
may  be  passed  from  :(8  to  21  centimetres  before  the  urine 
will  flow.  But  when  the  bladder  is  full  enough  to  cause 
a  desire  to  micturate,  showing  that  the  urine  has  entered 
the  prostatic  urethra,  the  flow  will  take  place  when  the 
catheter  has  been  passed  from  16  to  19  centimetres. 

From  all  this  it  would  seem  that  when  the  bladder  is 
either  empty  or  but  moderately  distended  it  is  closed  by 
the  internal  prostatic  sphincter  ;  when  it  is  fully  distended, 
this  function  is  performed  by  the  external  prostatic 
sphincter  and  the  compressor  urethras. 

I  have  here  given  somewhat  fully  Finger's  view  of  the 
action  of  the  sphincter  of  the  bladder,  as  it  has  been 
largely  adopted,  and  affords  a  ready  explanation  of  many 
of  the  phenomena  met  with  in  urethritis.  There  are, 
however,  reasons  for  believing  that  the  sphincter  of  the 
bladder  (the  internal  prostatic  sphincter)  plays  a  far  more 
important  part  than  Finger  and  Guyon  credit  it  with,  and 
that  under  ordinary  circumstances  it  is  by  this  muscle 
that  the  bladder  is  closed  whether  distended  or  not.  And 
there  is  evidence*  that  when  the  internal  sphincter  does 

*  M.  V.  Zeissl,  '  Ueber  die  Innervation  der  Blase,'  Arch.  f.  d.  gcs. 
P/iysio/flg.,  Bd.  53  ;  'Ueber  die  Innervation  der  Blase,'  Wiener  Klitiik, 
1901,  Heft.  5  ;  'Weitere  Untersuchungen  iiber  die  Innervation  der 
Blase  und  der  Harnrohre,' ^rir//./.  d.  ges.  P/iysiolog.,  Bd.  89,  1902. 
A.  Hanc,  '  Experinientelle  Studien  iiber  den  Reflexmechanismus  der 
Hahnblase,'  Pfliigcrs  Afch.  f.  d.  ges.  Physiolog,  Bd.  73.  v.  Frankl- 
Hochwart  and  Frohlich,  Mendels  Netirolog.  Zcntralbl.^  1904,  ^^o.  14. 


lo      Treatment  of  Gonorrhoea  in  the  Male 

yield,  it  does  so,  not  because  it  is  overcome  by  the 
mechanical  pressure  of  the  urine  in  the  bladder,  but 
because  its  muscular  hbres  relax  as  a  vital  act  in  response 
to  a  nerve  impulse  preliminary  to  the  evacuation  of  the 
urine. 

The  normal  act  of  micturition  would  appear  to  be  as 
follows :  As  the  bladder  becomes  distended  with  urine  the 
vesical  nerves  are  stimulated,  and  evoke  stronger  and 
stronger  contractions  of  the  detrusor  muscles,  giving  rise 
to  the  desire  for  micturition.  To  withstand  the  increased 
pressure  of  the  urine,  the  tone  of  the  internal  unstriped 
muscular  sphincter  is  increased,  and,  if  necessary,  even 
the  accessory  voluntary  urethral  muscles  are  called  into 
play.  When  a  favourable  opportunity  for  micturition 
occurs,  the  internal  sphincter  is  voluntarily  relaxed, 
together  with  the  rest  of  the  unstriped  muscular  tissue 
of  the  posterior  urethra,  and  the  urine  is  expelled  1)\-  the 
contraction  of  the  detrusors. 

The  objection  which  has  been  raised  to  an  unstriped 
muscle,  like  the  internal  sphincter,  being  under  the 
influence  of  the  will  is  fairly  met  by  a  reference  to  the 
accommodation  muscle  of  the  eye,  which,  whilst  unstriped, 
is  completely  under  the  control  of  the  will. 

Finger,  in  support  of  the  theory  that  as  the  bladder 
becomes  distended  the  pressure  of  the  urine  causes  the 
elasticity  of  the  neck  of  the  bladder  and  the  internal 
sphincter  to  yield,  and  the  urine  to  enter  the  posterior 
portion  of  the  prostatic  urethra,  quotes  certain  experi- 
ments by  Born,*  who  injected  liquid  plaster  of  Paris 
down  the  ureter  of  certain  recently  killed  animals  so  as  to 
distend  the  bladder.  After  a  small  quantity  had  been 
injected  under  slight  pressure  and  had  set,  the  cast  of  the 
bladder  had  the  form  of  an  egg,  and  was  sharpl}'  cut  off 
*  Zcitsiii7-ift Jiir  Chirur^ic^  lUl.  25,  S.  135. 


1  -       Treatment  of  Gonorrhoea  in  the  Male 

from  the  urethra  by  the  internal  sphincter.  \\'hen  a 
large  quantity  was  injected  under  greater  pressure  the 
cast  was  pear-shaped,  on  account  of  the  prostatic  urethra 
having  been  taken  up  into  the  bladder  so  as  to  form  a 
*  bladder-neck.' 

These  e.xperiments  on  the  dead  bodies  of  animals  are, 
however,  so  crude,  and  carried  out  under  circumstances 
so  totally  unlike  those  met  with  during  life,  that  no  weight 
can  be  attached  to  tiieir  results.  I  have  repeated  this 
experiment  under  more  natural  conditions,  and  obtained 
very  different  results.  I  injected  the  bladders  of  certain 
men  and  youths  with  a  suspension  of  bismuth,  and  then 
radiographed  the  pelvis.  In  every  case  I  found  that, 
whether  the  bladder  was  fully  distended  or  not,  the  out- 
line of  the  organ  was  oval  and  not  pear-shaped,  and  the 
urethra  was  sharply  cut  off  from  the  bladder  without  a 
suggestion  of  a  '  bladder-neck,'  as  shown  in  Fig.  5,  which 
was  taken  from  a  radiograph  of  the  pelvis  of  a  man  whose 
bladder  had  been  previousl}-  fully  distended  by  the  injec- 
tion of  a  suspension  of  bismuth.  A  fine  metal  bougie  has 
been  passed  into  the  bladder  in  order  to  show  the  position 
of  the  urethra.  It  would  be  out  of  place  to  discuss  this 
question  further  here.  I  have  treated  it  at  greater  length 
elsewhere. 

Before  turning  from  the  anatomy  of  this  part,  it  ma\-  be 
well  to  say  a  few  words  respecting  the  compressor  urethra: 
muscle. 

This  muscle  plays  a  very  important  part  in  the  pro- 
duction of  what  is  commonl}-  called  spasm  of  the  urethra. 
If  in  a  healthy  person  a  simple  bougie  be  passed,  as  the 
instrument  enters  the  membranous  portion  the  walls  of 
the  urethra  contract,  so  as  to  grasp  the  bougie  and  some- 
what hinder  its  progress  towards  the  bladder.  This  arises 
from  the  bougie  having  stimulated  the   ner\-e-endings  of 


Anatomy  of  the  Urethra  and  Bladder        i  3 

the  mucous  membrane,  and  hrcjiij^liL  ;i.1joiiI  a  conlraclioii 
of  the  compressor  urethr^e  muscle.  When  the  urethra  is 
inflamed,  the  sh'ghtest  irritation  to  the  mucous  membrane, 
such  as  is  caused  by  the  passage  of  urine,  may  give  rise  tfj 
so  violent  a  spasm  of  this  muscle  as  to  cause  retention  of 
urine.  When  the  irritation  is  very  great  all  tin;  muscular 
fibres  in  and  about  the  urethra  are  spasmodically  con- 
tracted, but  usually  the  spasm  is  limited  to  the  compressor 
urethral  and  the  muscular  fibres  about  the  membranous 
urethra. 

This  spasmodic  contraction  may  be  called  forth,  not 
only  by  the  passage  of  a  foreign  body  like  a  bougie,  but 
also  by  the  pressure  and  irritation  of  fiuids  ;  and  thus  it 
happens  that  even  an  unirritating  liuid  injected  up  the 
healthy  urethra  is  prevented  from  entering  the  mem- 
branous urethra  by  the  contraction  of  the  compressor 
muscle.  Still  more  marked  becomes  the  spasm  when  an 
astringent  or  irritating  fiuid  is  injected  up  an  infiamed 
urethra.  And  thus  it  is  that  in  the  treatment  of  acute 
urethritis  (to  be  presently  considered)  the  injection  is 
prevented  from  entering  the  membranous  and  prostatic 
portions  of  the  urethra  by  a  contraction  of  the  compressor 
urethrae. 

It  is  true  that  under  an  anaesthetic,  or  by  the  adoption 
of  certain  measures  which  will  be  referred  to  later,  it  is 
possible  to  fill  the  bladder  by  injecting  fiuid  into  the 
meatus.  But  this  in  no  wise  contradicts  the  established 
fact  that  fluids  injected  with  an  ordinary  gunorrhaal  syringe 
do  not  usually  pass  beyond  the  bulbous  urethra. 

Now,  just  as  the  compressor  muscle  prevents  the  passage 
of  fluids  to  the  bladder,  so  it  prevents  tiuids  from  passing 
the  opposite  way,  viz.,  from  the  bladder  to  the  meatus. 

Therefore,  if  pus  or  blood  be  present  in  the  urethra 
behind  the  compressor  muscle,  the  liuid  will  tend  to  pass 


14      Treatment  of  Gonorrhoea  In  the  Male 

backwards  into  the  bladder  rather  than  forwards  towards 
the  meatus. 

//  will  be  seen  tJuxt  the  compressor  muscle  thus  sharply 
separates  the  urethra  into  tico  portions,  an  anterior  and  a 
posterior  portion,  xchich  division  is  of  the  greatest  importance 
for  the  proper  understanding  of  the  pathology,  symptoms,  and 
treatment  of  gonorrJia'a. 


CHAPTER  III 

ACUTE  URETHRITIS 

This  disease  arises  from  an  inoculation  of  the  urethral 
mucous  membrane  at  the  meatus  with  the  specific  virus — 
the  gonococcus.  The  inoculation  soon  gives  rise  to  an 
acute  catarrhal  inflammation,  which  spreads  as  far  as  the 
bulb,  but  not,  under  favourable  circumstances,  beyond  it. 
If  the  inflammation  spread  beyond  the  bulb  to  the  posterior 
urethra,  this  extension  must  be  regarded  as  a  distinct  com- 
plication, which  brings  in  its  train  new  and  unfavourable 
symptoms,  and  calls  for  a  different  mode  of  treatment. 
The  extension  of  the  inflammation  is  of  frequent  occur- 
rence ;  how  frequent  it  is  difficult  to  say,  for  much 
depends  on  the  way  the  disease  has  been  treated,  but, 
roughly  speaking,  in  So  per  cent,  of  all  cases  of  urethritis 
of  over  six  weeks'  duration  the  posterior  urethra  becomes 
infected. 

Acute  Anterior  Urethritis. 

Incubation.  —  A  short  period  elapses  between  the 
inoculation  of  the  urethral  mucous  membrane  with  the 
virus  of  the  disease  and  the  appearance  of  the  first  svmp- 
toms  of  the  same.  This  period  of  incubation  varies 
within  certain  limits.  It  may  be  as  brief  as  one  or  two 
days  only,  or  it  may  extend  to  two,  or  even  three,  weeks, 
but  in  three-fourths  of  the  cases  it  is  confined  to  the  limits 
of   one    week.     Most    commonly  the  first   svmptoms  are 

15 


1 6       Treatment  of  Gonorrhoea  in  the  Male 

noticed  on  the  third  or  fourth  day  after  infection.  It  very 
rarcK'  occurs  that  the  period  of  incubation  is  kss  than  two 
days.  Instances  recorded  as  such  are  generally  to  be  ex- 
plained as  exacerbations  of  latent  chronic  gonorrhoea,  and 
not  as  fresh  infections. 

Symptoms. — Generally,  the  first  symptom  noticed  by 
the  patient  is  a  slight  burning  or  tingling  sensation,  felt 
at  the  end  of  the  penis,  especially  on  micturition.  The 
lips  of  the  meatus  then  become  swollen,  everted,  and 
moistened  with  a  slight  tenacious,  mucous  secretion, 
which  rapidly  becomes  copious  and  purulent.  During 
the  next  few  days  the  pain  on  micturition  increases 
considerably,  so  much  so  that  the  patient  dreads  to 
make  water.  The  discharge  rapidly  passes  from  clear 
mucus  to  muco-pus,  and  then  to  thick  creamy  yellow  or 
greenish-yellow  pus,  which  is  secreted  so  profusely  as  to 
be  constantly  dropping  from  the  meatus.  As  a  rule,  the 
penis  is  red  and  swollen,  and  the  prepuce  oedematous,  so 
that  the  glans  is  uncovered  with  difficulty.  Not  un fre- 
quently the  lymphatics  of  the  organ  are  inflamed,  and 
appear  as  thin  red  streaks  in  the  integuments  of  the  penis; 
and  the  lymphatic  glands  of  the  groin  are  swollen  and 
tender. 

Distressing  sexual  symptoms  are  seldom  absent,  the 
inflammatory  irritation  of  the  parts  inducing  increased 
sexual  desires.  In  the  earliest  stages  of  the  disease  this 
condition  often  provokes  the  patient  to  sexual  excesses ; 
but  as  the  inflammation  increases  all  voluptuous  feelings 
are  lost  in  the  intense  pain  which  an  erection  of  the  in- 
flamed organ  evokes.  These  painful  erections,  often  accom- 
panied by  seminal  emissions,  form  a  characteristic  feature 
of  the  acutest  stage  of  the  disorder,  and  seriously  interfere 
with  the  night's  rest  and  sleep. 

The  inflamed  condition  of  the  urethra  and  the  corpus 


Acute  Urethritis  17 

spongiosum  renders  IIkmii  less  elastic  than  usual.  Conse- 
quently, when  the  penis  becomes  swollen  and  erect,  it 
curves  downward  to  a  greater  or  less  degree,  and  the  in- 
flamed urethra  can  be  felt  as  a  cord  holding  down  the 
penis,  hence  the  term  chorda  venerea.  These  erections  of 
the  inflamed  organ  are  naturally  accompanied  by  severe 
pain,  and  in  consequence  are  dreaded  by  the  patient.  At 
these  times  it  not  infrequently  happens  that  the  pus  is 
tinged  with  blood,  which  has  escaped  from  the  engorged 
capillaries  of  the  urethral  mucous  membrane. 

Considering  the  severity  of  the  local  symptoms,  it  is 
surprising  how  little  the  general  constitution  is  affected. 
Apart  from  a  slight  pallor  of  the  face,  loss  of  appetite,  and 
feeling  of  malaise,  the  general  condition  is  hardly  impaired. 
During  the  acme  of  the  inflammation  a  trifling  rise  of 
temperature  may  be  noted,  but  rarely  more  than  these 
effects  are  produced. 

The  symptoms  generally  increase  in  severity  up  to  the 
second  or  third  week ;  and  then,  if  all  goes  w^ell,  a  change 
for  the  better  begins  to  take  place.  The  inflammation 
slowly  dies  down,  and  the  symptoms  abate.  The  secretion 
becomes  thinner,  more  mucoid,  and  lessened  in  quantity, 
until  at  length  only  sufficient  remains  to  glue  the  lips  of 
the  meatus  together.  It  then  disappears,  so  that  at  the 
end  of  the  fifth  or  sixth  week  the  entire  process  is  over, 
and  the  disease  is  cured. 

This  may  be  regarded  as  the  normal  and  most  favour- 
able course,  but  it  is  liable  to  many  exceptions.  Apart 
from  the  occurrence  of  the  special  complications  to  which 
this  disease  is  so  peculiarly  liable,  and  which  are  more 
conveniently  discussed  elsewhere,  the  course  of  the  dis- 
order may  be  affected  in  the  following  ways :  (a)  By  an 
exacerbation  or  recurrence  of  the  acute  inflammation  ; 
(6)  by  an  extension  of  the  disease  to  the  posterior  urethra  ; 

2 


iS      Treatment  of  Gonorrhoea  in  the  Male 

and  (c)  bv  the  inflammation  passing  into  a  chronic  condi- 
tion.    These  \vc  will  consider  separately. 

An  Exacerbation  of  the  Acute  Inflammation. 

Little  need  be  said  on  an  exacerbation  of  the  acute  inflam- 
mation. It  not  infrequently  arises  from  some  indiscretion 
in  diet,  more  especially  in  the  use  of  alcohol,  or  by  sexual 
excitement,  or  unsuitable  local  treatment.  Such  relapses 
ma\-  occur  again  and  again.  These  not  only  greatl)'  delay 
the  recovery  of  the  patient,  but  are  often  most  potent 
factors  in  bringing  about  an  extension  of  the  inflammation 
to  the  posterior  urethra,  and  in  causing  the  disorder  to 
become  chronic. 


CHAPTER  IV 

ACUTE  POSTERIOR  URETHRITIS 

About  the  beginning  of  the  third  week  the  inflammation 
in  the  anterior  portion  of  the  urethra  reaches  its  acme, 
and  unless  it  extend  further  along  the  urethra,  will  either 
entirely  disappear  or  gradually  pass  into  the  chronic 
stage.  Should  it,  however,  extend  to  the  posterior 
urethra,  the  prognosis  is  considerably  graver ;  the  risk 
of  such  complications  as  epididymitis,  cystitis,  prostatitis, 
and  spermato-cystitis  being  very  great. 

The  frequency  of  the  extension  of  the  inflammation  to 
the  posterior  urethra  is  variously  estimated  by  different 
writers.  This  discrepancy  arises  from  different  tests  being 
used  to  detect  the  extension,  and  also  from  the  fact  that 
this,  like  all  other  complications  of  this  disease,  varies 
according  to  the  social  position  of  the  patient  and  his 
ability  or  inability  to  rest.  But  all  authorities  are  agreed 
that  it  is  a  complication  more  frequently  present  than 
absent.  Jadassohn  (1889)  detected  it  in  87*7  per  cent, 
of  all  cases  of  urethritis  of  from  four  to  six  weeks'  dura- 
tion ;  Rona  in  go  per  cent.  ;  Finger  gives  63  per  cent,  for 
his  private,  and  82  per  cent,  for  his  hospital,  cases. 

The  reason  for  the  extension  of  the  inflammation  to  the 
posterior  urethra  is  not  always  easy  to  detect,  but  an3-thing 
which  tends  to  aggravate  the  disease,  such  as  excessive 

19  2 — 2 


20      Treatment  of  Gonorrhoea  in  the  Male 

lx>dily  exercise,  venereal  or  alcoholic  excess,  or  iiritalinj^ 
injections  during;  tlie  early  stages  of  the  disorder,  seem  to 
be  the  most  fre(]uent  causes. 

It  is  not  (juite  clear  win'  the  inllammalion  so  freciueiitly 
stops  at  the  bulbous  urethra.  Guyon  believes  that  the 
further  extension  of  the  inllammation  is  prevented  by  the 
action  of  the  compressor  urethrje.  But  it  is  difficult  to 
understand  how  a  muscle,  however  powerful,  can  sto)^ 
the  advance  of  a  \  iruKnt  eataniial  inllaminalion  along  an 
uninterrupted  mucous  membrane. 

Finger  thinks  it  is  probably  due  to  the  fact  that  the 
gonococcus  has  a  special  tendency  to  develop  most 
luxuriantly  in  glandular  tissue,  the  infection  spreading 
from  follicle  to  follicle.  Whilst  the  pendulous  portion  of 
the  urethra  is  rich  in  follicles  and  also  in  numerous  glands 
and  crypts,  increasingly  so  towards  the  bulbous  urethra, 
the  membranous  portion  is  free  from  all  follicles.  These 
only  appear  again  in  the  prostatic  urethra,  to  cease  at 
the  vesical  orifice.  Finger  suggests  this  as  an  explanation 
of  the  tendency  of  the  inflammation  to  be  arrested  at  the 
beginning  of  the  membranous  urethra  and  again  at  the 
orifice  of  the  bladder.  A  more  simple  explanation  would 
be  to  regard  the  extent  to  which  the  inflammation  spreads 
as  merely  dependent  upon  the  virulence  of  the  infection 
and  the  degree  of  resistance  offered  by  the  tissues. 

Symptoms.— The  extension  of  the  inflammation  to  the 
posterior  urethra  may  manifest  itself  by  the  sudden  onset 
of  painful  symptoms,  or  it  may  develop  so  insidiously  as 
hardly  to  attract  the  notice  of  the  patient.  The  most 
frequent  and  by  far  the  most  distressing  symptom  is  an 
excessive  irritability  of  the  prostatic  mucous  membrane, 
causing  a  constant  desire  to  micturate.  The  intensity  of 
this  symptom  is  proportionate  to  the  degree  of  inflamma- 
tion.    In  the  acutest  cases  the  desire  to  micturate  scarcely 


1 


Acute  Posterior  Urethritis  21 

ever  abates,  and  is  iiulepenclcnt  of  the  ninrjiiiit  of  iiiiiK;  in 
the  bladder. 

Another  common  symptom  is  lucnnaliwia.  The  last  few 
drops  of  urine  and  pus  are  stained  with  blood,  which  has 
been  pressed  out  of  the  inflamed  mucous  membrane  of  the 
membranous  portion  by  the  contraction  of  the  compressor 
urethrse.  As  a  rule,  the  bleeding  is  limited  to  a  few  drops 
of  bright  blood  passed  at  the  end  of  micturition,  but  at 
times  the  hemorrhage  is  free.  This,  unfortunately,  often 
leads  to  an  entirely  erroneous  diagnosis,  and  the  unhappy 
patient  is  subjected  to  an  instrumental  examination  of  the 
bladder. 

A  third  symptom  of  this  condition  is  that  of  frequent 
seminal  emissions.  This  symptom,  which  is  seldom  absent, 
is  due  to  the  irritation  of  the  caput  gallinaginis.  Its  occur- 
rence during  the  third  or  fourth  week  of  an  attack  of 
acute  gonorrhoea  should  cause  the  surgeon  to  suspect  the 
presence  of  posterior  urethritis. 

In  addition  to  these  three  cardinal  local  symptoms, 
there  is  usually  some  constitutional  disturbance,  slight 
fever,  and  a  decided  feeling  of  malaise. 

In  a  considerable  proportion  of  cases  of  posterior 
urethritis  the  urine,  though  filtered  free  from  pus  cells, 
etc.,  shows  the  presence  of  albumin  when  tested  by  boiling 
or  by  the  addition  of  nitric  acid.  The  amount  of  albumin 
is  out  of  all  proportion  to  the  quantity  of  pus  present,  and 
cannot  be  explained  on  the  supposition  that  it  represents 
the  albumin  of  the  serum  or  liquor  puris.  If  the  urine 
from  a  case  of  acute  anterior  urethritis  be  filtered,  the 
filtrate  scarcel}^  shows  the  presence  of  albumin,  notwith- 
standing the  large  amount  of  pus  present  in  the  urine. 
No  satisfactory  explanation  of  this  albuminuria  has  been 
given,  but  its  presence  is  an  unfavourable  sign,  and  calls 
for  special  care  in  the  application  of  local  remedies.     The 


2  2      Treatment  of  Gonorrhoea  in  the  Male 

origin  of  this  albuminuria  is  doubtful.  Finger  and  Nisch- 
kovsky  maintain  that  it  is  closely  associated  with  the 
vesical  tenesmus,  increasing  and  decreasing  pari  passu 
with  this  condition.  This  statement  is  not  in  accordance 
with  my  own  observations,  Runeberg  and  Ultzmann 
believe  that  it  arises  from  the  back  pressure  of  the  urine 
in  the  ureters  in  consecjuence  of  the  spasm  of  the  vesica* 
sphincter. 

Unfortunately  for  the  patient,  an  acute  posterior  ureth- 
ritis is  often  but  a  prelude  to  further  and  more  serious 
complications.  The  most  common  of  these  is  an  epidi- 
dymitis produced  by  the  inilammation  extending  up  the 
ejaculatory  ducts.  Less  commonly  the  vesicles  are  in- 
fected in  like  manner.  Again,  just  as  the  inflammation 
may  spread  from  the  anterior  to  the  posterior  portion  of 
the  urethra,  so  may  an  acute  posterior  urethritis  give  rise 
to  a  cystitis. 

Diagnosis. — The  easiest,  and  in  most  cases  the  best, 
way  of  proving  the  presence  or  absence  of  posterior 
urethritis  is  by  means  of  the  '  two-glass  test  '  of  Sir  Henry 
Thompson.  It  is  applied  in  the  following  manner:  The 
patient  on  first  rising  in  the  morning  passes  his  urine  into 
two  urinary  glasses,  half  emptying  his  bladder  into  one 
glass,  and  then  passing  the  remainder  into  the  second 
glass.  Should  he  be  suffering  from  anterior  urethritis, 
the  urine  in  the  first  glass  will  appear  turbid  from  the 
presence  of  pus,  which  the  flow  of  urine  has  brought 
away ;  but  the  second  portion  of  urine  will  be  quite  clear, 
for  the  urethra  has  been  swept  free  of  pus  by  the  first 
portion  passed.  But  if  it  be  a  case  of  posterior  urethritis, 
not  only  will  the  first  portion  of  urine  be  turbid,  but  the 
second  also.  It  is  obvious  that  this  turbidity  of  the 
second  portion  can  only  be  due  to  a  turbidity  of  the 
urine   within    the  bladder.     As  the  first  portion  of  urine 


Acute  Posterior  Urethritis  23 

passed  removes  ;l11  the  pus  from  the  urethra,  if  jlir  m  ine 
within  the  bladder  be  clear,  the  second  portion  must  be 
clear  also.  The  pus  in  the  anterior  urethra  is  prevented 
from  passing  backwards  by  the  strouj:;  compressor  urethrse 
muscle,  but  it  is  free  to  pass  forwards,  and  is,  indeed, 
aided  by  gravity.  But  it  is  different  with  the  pus  found 
in  the  posterior  urethra.  Here  the  compressor  muscle 
prevents  it  passing  forwards ;  it  is  free,  however,  to  pass 
backwards  into  the  bladder,  where  it  mixes  with  the  urine 
collected  there.  Finger  believes  that  the  passing  of  the 
pus  backwards  into  the  bladder  is  aided  in  that,  as  this 
organ  becomes  distended  it  encroaches  upon  the  prostatic 
urethra,  and  thus  promotes  the  mixing  of  the  pus  with  the 
urine.  The  drawing  up  of  the  prostatic  urethra  into  the 
bladder,  if  it  occurs  at  all — and  we  have  given  reasons  for 
doubting  it  (see  p.  12) — does  so  when  the  bladder  is 
distended,  as  usually  occurs  during  the  night.  When 
pus  has  made  its  way  into  the  bladder  it  settles  to  the 
bottom  of  that  organ,  the  urine  collecting  above.  When 
the  urine  is  first  passed  in  the  morning  both  portions  are 
turbid,  as  a  rule  the  first  being  the  more  turbid.  But  if 
the  urine  be  tested  in  the  same  way  as  described  above 
during  the  day,  when  the  urine  is  not  retained  for  so 
long  a  period  as  during  the  night,  it  frequently  happens 
that  the  second  portion  of  urine  is  quite,  or  almost, 
clear. 

Tliis  difference  in  the  turbidity  of  the  second  portion  of  urine 
according  to  the  time  of  the  day  is  one  of  the  chief  diag- 
nostic signs  of  posterior  iircthritis,  and  distinguishes  it  from 
cystitis,  in  which  the  turbidity  of  the  urine  is  constant, 
and  the  second  portion  thicker  than  the  first.  Hence  the 
importance  of  the  rule,  when  testing  for  the  presence  of 
posterior  urethritis,  to  examine  the  urine  first  passed  on 
rising. 


24      Treatment  of  Gonorrhoea  in  the  Male 

Jadassohn's  Three-urine-glass  Test.— At  times  there 
is  an  advantage  in  making  use  of  three  urine  glasses  in 
tiie  way  suggested  by  Jadassohn.  The  patient  having 
passed  the  greater  part  of  his  urine  into  the  first  and 
second  glasses,  passes  the  last  portion  into  the  third  glass. 
The  first  glass  will  then  contain  any  pus  or  secretion 
which  was  present  in  the  urethra.  The  second  glass  will 
contain  urine  turbid  with  pus  if  any  should  have  been 
regurgitated  into  the  bladder.  The  third  glass  collects 
the  last  portion  of  urine  from  the  fundus  of  the  bladder, 
plus  any  blood,  pus,  or  secretion  which  the  powerful  con- 
traction of  the  compressor  urethrae  may  squeeze  out  of 
the  prostatic  gland.  This  three-glass  test  is  principally 
used  in  the  differential  diagnosis  of  posterior  urethritis 
and  that  of  cystitis.  Should  cystitis  be  present,  the  urine 
passed  into  the  third  glass  will  usually  be  more  turbid 
than  that  in  the  first  and  second  glasses. 

Kollmann's  Five-grlass  Test. — Kollmann  uses  a  five- 
glass  test.  The  principle  of  the  procedure  is  to  thoroughly 
cleanse  the  anterior  urethra,  and  then  to  allow  the  patient 
to  urinate  into  three  glasses.  A  catheter  of  hard  rubber 
with  the  eye  closed  to  the  end  is  passed  into  the  bulbous 
urethra,  and  with  this,  using  a  6  -  ounce  syringe,  the 
anterior  urethra  is  thoroughly  washed  out,  and  the  wash- 
ings collected  in  the  first  urine  glass.  The  irrigation 
is  carried  on  until  the  escaping  fluid  of  the  last  irrigation 
is  free  from  shreds  and  mucus.  When  it  is  certain 
that  all  shreds  have  been  removed  from  the  anterior 
urethra,  the  fluid  of  the  last  irrigation  is  collected  in 
the  second  urine  glass,  the  so-called  '  control  glass.'  The 
patient  then  micturates  successively  into  three  classes — 
viz.,  glasses  Nos.  3,  4,  and  5.  The  contents  of  these 
glasses  are  interpreted  as  in  Jadassohn's  three  -  glass 
test. 


Acute  Posterior  Urethritis 


-':) 


Acute  Anterior 

Acute  Posterior 

(.'y.stitis. 
First  portion'  loudy 

Two- 

Urethritis. 

Urethritis. 

P'irst  portion  cloudy 

First  pfjrtion  cloudy 

urine- 

Second  portion  clear 

Second     portion 

Second  jjorlion  al- 

glass 

cloudy,       though 

ways     cloudy, 

test 

less  so  than  first 

generally  more  so 

portion* 

than  the  firstpor- 

Three- 

tion 

P'irst  portion  cloudy 

First  portion  cloudy 

First  portion  cloudy 

glass 

Second  portion  clear 

■generally 

Second     portion 

test 

Third  portion  clear 

cloudy, 

cloudy 

Second 

though 

Third  portion  more 

Third 

less  so 
than    first 
portion 

cloudy  than   first 
and  second  por- 
tions 

Although  usually  sufficient  pus  is  formed  in  the  pos- 
terior urethra  to  regurgitate  at  some  time  or  other  of 
the  day  into  the  bladder,  occasionall}^  the  amount  pro- 
duced is  too  small  to  do  so.  In  these  cases  the  first 
portion  of  urine  will  carry  away  all  the  pus  from  the 
whole  of  the  urethra,  and  the  second  portion  will  conse- 
quently be  clear.  Therefore  the  constant  absence  of 
turbidity  in  the  second  portion  of  urine  does  not  positively 
exclude  the  presence  of  posterior  urethritis,  although  it  is 
strong  presumptive  evidence  in  favour  of  its  absence. 

The  best  way  of  determining  the  presence  or  absence  of 
posterior  urethritis,  in  case  of  doubt,  is  to  wash  the  anterior 
urethra  free  from  all  secretion  before  the  patient  passes  water. 
If  the  urine  after  this  contains  pus,  it  must  have  come  from  the 
posterior  portion. 

The  performance  of  this  manoeuvre  requires  some  little 
care.  An  elastic  catheter  is  passed  down  the  urethra  as 
far  as  the  bulb,  and  then  under  gentle  pressure  the  anterior 

*  The  second  portion  is  not  always  cloudy,  but  varies,  sometimes 
cloudy,  sometimes  clear. 


26      Treatment  of  Gonorrhoea  in  the  Male 

urethra  is  irrigated  with  boracic  sohition.  The  fluid,  pre- 
vented by  the  compressor  urethrje  from  passing  beyond  it, 
escapes  at  the  meatus,  carrying  with  it  any  secretion 
lodged  in  the  anterior  portion.  The  irrigating  fluid 
should  be  cold,  so  that  it  may  cause  a  more  active  con- 
traction of  the  compressor  muscle.  The  irrigation  is 
continued  till  the  boracic  solution  returns  (]uite  clear  and 
free  from  all  secretion.  As  the  fluid  escapes  from  the 
meatus  it  is  collected  in  a  glass  for  comparison  with  the 
urine  subsequently  passed. 

Care  must  be  taken  that  the  fluid  be  not  injected  too 
forcibly,  lest  the  resistance  of  the  compressor  be  overcome 
and  the  test  be  nullifled.  A  ready  means  of  determining 
whether  the  fluid  has  passed  into  the  posterior  urethra  or  not 
is  to  irrigate  with  solution  of  iodide  of  potassium  (i  :  looo) 
instead  of  the  boracic  fluid.  Then,  the  patient  having 
micturated,  add  to  the  urine  a  drop  or  two  of  perchloride 
of  iron  solution.  If  the  fluid  has  been  forced  into  the 
posterior  urethra,  a  characteristic  blue  colour  will  be  pro- 
duced, showmg  that  the  irrigation  has  not  been  properly 
performed  (Lohnstein). 

In  discussing  the  diagnostic  \alue  of  the  tests  by  two, 
three,  and  five  glasses,  it  has  been  assumed  that  the 
turbidity  of  the  urine  was  due  to  the  presence  of  pus  or 
mucus,  and  not  to  other  causes.  In  practice  this  point 
must  be  determined  by  a  microscopical  and  chemical 
examination  of  the  urinary  deposit.  For  not  infrequently 
the  urine  of  patients  suffering  from  gonorrhoea  is  cloudy 
from  the  presence  of  phosphates.  A  much  rarer  cause  of 
the  urine  appearing  turbid  is  the  presence  of  large 
numbers  of  micro-organisms,  more  especially  of  the  coli 
group.  In  the  first  case  a  few  drops  of  dilute  acetic  acid 
added  to  the  urine  will  at  once  dissolve  the  phosphates 
and  render  the  urine  clear  ;  in  the  second  case,  a  micro- 
scopical examination  reveals  the  cause  of  the  turbidity. 


CHAPTER  V 

THE  BACTERIOLOGICAL  DIAGNOSIS   OF   GONORRHCEA 

Before  making  a  prognosis  or  deciding  on  a  line  of 
treatment  in  a  case  of  urethritis,  it  is  necessary  to  de- 
termine whether  the  inflammation  present  is  due  to 
gonorrhoea  or  not. 

Although  gonorrhoea  is  responsible  for  the  great 
majority  of  cases  of  urethritis,  it  is  beyond  dispute  that 
occasionally  other  causes  may  give  rise  to  this  malady. 
The  chief  of  these  causes  are:  (a)  Mechanical  irritation, 
such  as  the  passage  of  a  rough  urinary  calculus ;  and 
(6)  chemical  irritation,  such  as  would  be  produced  by  the 
intra-urethral  injection  of  an  irritating  fluid. 

The  inflammation,  which  is  the  result  of  mechanical  or 
chemical  irritation,  differs  so  markedly  from  gonorrhoea, 
however,  that,  even  in  the  absence  of  all  history  of  the 
case,  there  is  little  likelihood  of  the  two  conditions  being 
confused.  The  inflammation  caused  by  traumatic  or 
chemical  agencies  develops  immediately  after  the  receipt 
of  the  injury,  and  so,  unlike  gonorrhoea,  is  devoid  of  an 
incubative  period.  Moreover,  the  inflammation  rapidly 
attains  its  acme,  generall}'  within  the  space  of  a  few  hours, 
and  as  quickly  subsides  ;  and,  further,  it  has  no  tendency 
to  spread  along  the  urethra  or  to  become  chronic.  All 
this  is  typically  represented  by  the  inflammation  pro- 
voked by  the  injection  of  a  strong  solution  of  nitrate  of 


:'S      Treatment  of  Gonorrhoea  in  the  Male 

silver.  Hut,  apart  from  the  above-mentioned  causes,  a 
purulent  urethritis  may  be  produced  by  an  inoculation  of 
the  urethra  with  micro-organisms  other  than  the  gono- 
coccus.  The  ordinary  micro-organisms  of  sepsis  seem 
capable,  under  certain  conditions,  of  producing  a  mild 
purulent  condition.  This  is  a  probable  explanation  of 
those  rare  cases  in  which  a  purulent  discharge  has 
developed  in  a  health)-  man  after  coitus  with  a  health}' 
menstruating  woman,  or  one  suffering  from  leucorrhcea 
of  non-specific  origin.  That  such  an  infection  may  take 
place  seems  well  established.  The  majority  of  the 
reported  cases,  however,  are  probably  examples  of  latent 
chronic  gonorrhoea,  acquired  perhaps  long  before,  which 
has  been  rekindled  by  sexual  or  other  stimuli.  But  on 
this  point  more  will  be  said  subsequently.  Although  the 
bacteriology  of  this  pseudo-gonorrhcea  has  attracted  much 
attention,  there  is  but  little  uniformity  in  the  statements 
as  to  the  micro-organisms  found  to  be  present.  Apart 
from  the  common  pus  cocci,  a  short,  slender  bacillus  and 
a  diplococcus  have  been  commonly  described.  But  there 
is  no  reason  to  suppose  that  either  of  these  plays  a 
specific  role. 

The  bacteriological  diagnosis  of  gonorrhoea  rests  upon 
the  detection  of  the  specific  micro-organism,  the  gono- 
coccus,  within  the  pus.  In  the  acute  stage  of  the  disease 
the  cocci  are  present  in  such  large  numbers  that  their 
detection  is  one  of  the  easiest  of  bacteriological  tasks. 
All  that  is  necessary  is  to  smear  a  drop  of  the  urethral 
pus  upon  a  clean  glass  slide,  dry  it  gently  with  heat,  and 
then  stain  it  for  a  minute  or  two  with  an  alkaline  solution 
of  methylene  blue.  The  stain  is  then  washed  off  with 
water  and  the  slide  allowed  to  dry.  A  drop  of  cedar  oil  is 
now  placed  on  the  stained  film  (a  cover-slip  is  unnecessary), 
and   the    slide   examined    with   a  yV-inch    oil  -  immersion 


Bacteriological  Diagnosis  of  Gonorrhoea 


2<) 


objective.  It  will  Ix;  noticed  fli;il  i1m-  pus  c;ells  huvc 
become  faintly  stained  with  the  Miic,  mid  the  large 
irregular  nuclei  more  deeply  so  ;  and  within  the  body  of 
the  pus  cells  the  cocci  will  be  found  stained  a  still  deeper 
— a  dark  blue  (Fig.  6).  The  gonococci  are  almost  always 
seen  in  pairs,  hence  the  term  '  diplococcus.'  They  arc 
further  grouped  together  in  fours  or  multiples  of  four. 
They  never  form  chains.     The  gonococcus  is  similar  in 


Fig.  6. — Acute   Gonorrhceal   Pus,  showing   Goxococci  ;  Pus    Cells 
WITH   Irregular  Nuclei.     (xi,ooo.) 

shape  to  a  bean,  the  concavities  of  the  twin  cocci  being 
opposite  to  each  other.  The  grouping  of  the  cocci  arises 
from  the  method  of  multiplication,  w^hich  is  by  fission. 
The  beginning  of  the  fission  is  indicated  by  the  concavit}-. 
The  line  of  fission  in  each  pair  is  at  right  angles  to  that 
of  the  previous  pair,  w^hence  the  tendency  to  the  formation 
of  groups  of  four  and  multiples  of  four  (see  Fig.  7). 

The    staining    of    the    pus    with    meth}"lene    blue,    as 
described  above,  is  in  most  cases  the  simplest  and  best 


30      Treatment  of  Gonorrhoea  in  the  Male 

method  of  demonstratinLj  the  presence  of  gonococci. 
Numerous  other  stains  have  been  advocated  from  time 
to  time  as  superior,  but,  after  a  careful  trial  of  them,  I 
find  that  there  is  little  to  recommend  them  save  their 
novelt}'.  No  method  has  hitherto  been  discovered  by 
which  the  gonococci  can  be  differentially  stained  from 
the  other  micro  -  organisms  ;  and,  short  of  this,  there 
seems  little  to  be  gained  by  fancifull)-  staining  the  pus 
cells. 

Of  the  double  stains  suggested,  that  of  Lanz*  may  be 
specially  recommended.  It  is  composed  of  4  parts  of  a 
saturated  solution  of  thionin  made  in  2^  per  cent,  carbolic 


0      a      G 


o 
o 


^  QO  00         00 

Fig.  7. — Diagrammatic  Representation  of  the  Multiplication 
of  the  gonococcus. 

water,  together  with  i  part  of  a  similar  solution  of  fuchsin. 
The  stain  is  used  in  the  following  manner  :  The  dried 
film  of  pus  is  immersed  in  the  mixture  from  fifteen  to 
thirty  seconds,  then  washed  in  water,  dried,  and  mounted. 
The  gonococci  are  stained  blue  by  the  thionin,  and  the 
pus  cells  red,  with  their  nuclei  bluish-red. 

The  gonococcus,  unlike  the  majority  of  the  pathogenic 
cocci,  does  not  retain  Gram's  stain. '      This  fact  is  largely 

*  Dciiisch.  mcd.  IVoc//.,  189S,  No.  40. 

t  Craiii's  Stain. — {a)  After  drying  and  fixing  the  film,  stain  for  five 
minutes  with  strong  anilin-gentian-violet  solution,  (b)  Without  wash- 
ing, treat  with  Gram's  iodine  solution  for  two  minutes  (iodine  i, 
iodide  of  potassium  2,  distilled  water  300).  {c)  Decolourize  in  absolute 
alcohol  until  no  more  violet  colour  is  seen  to  come  away. 


Bacteriological  Diagnosis  of  Gonorrhoea     ^ ' 

made  use  of  in  t\\i-  foniiin;^'  of  ;i.  diUcrcnti;!!  di.'L^^'nosis.  It 
must,  however,  be  borne  in  mind  tliat  Ciram's  staining 
reaction  is  not  an  infallible  test,  and,  therefort,-,  too  much 
reliance  must  not  be  placed  upon  it. 

The  gonococcus  does  not  grow  readily  under  artificial 
conditions.  On  ordinary  media,  such  as  gelatine  or  agar, 
it  will  not  grow  at  all,  and  even  when  special  media  on 
which  it  will  grow  are  used,  the  growth  is  never  luxuriant, 
and  it  quickly  ceases.  The  simplest  method  of  culti- 
vating it  for  clinical  purposes  is  to  smear  a  drop  of  fresh 
human  blood  or  serum  over  the  surface  of  a  sloped  agar 
tube,*  and  to  inoculate  the  thus  prepared  surface  with  a 
drop  of  pus  squeezed  out  of  the  deeper  portion  of  the 
urethra.  A  better  culture-medium,  when  available,  is 
made  by  mixing  i  part  of  human  serum  (hydrocele  fluid 
may  be  used)  with  two  parts  of  the  ordinary  peptone-agar 
medium.  The  tube  is  then  incubated  at  a  temperature  of 
37°  C.  At  the  end  of  twent3'-four  hours  the  colonies  of 
the  cocci  look  like  fine  drops  of  dew  dotted  on  the  surface 
of  the  agar.  At  the  end  of  three  days  they  cease  to  grow, 
and  soon  afterwards  die.  In  selecting  gonorrhoeal  pus 
for  examination  it  is  always  well  to  avoid  that  found  at 
the  meatus,  as  it  is  likely  to  be  contaminated  with  other 
micro-organisms.  Inoculation  experiments  cannot  be 
conducted  upon  animals,  they  being  immune  to  the 
gonococcus.  But  it  has  been  proved  that  the  gonococcus 
is  the  true  cause  of  gonorrhoea  by  successfull}^  inoculating 
the  urethra  and  conjunctiva  in  the  human  subject.^ 

The  bacteriological  diagnosis  of  gonorrhoea  is  often  of 
great  value,  more  especially  in  medico-legal  cases,  and, 
as  we  shall  see  later,  in  forming  a  decision  as  to  the 
definite   cure   of  the   chronic   condition.      In    the   acute 

*  Abel,  Deiitsch.  iiicd.  Woc/i.,  1893. 

t  Bumm,  Wertheim,  Finger,  and  others. 


3  2       Treatment  of  Gonorrhoea  in  the  Male 

stages  i)f  purulent  urethritis  there  is  rarely  any  dirficulty 
in  definitely  determining  the  presence  or  absence  of  the 
gonococcus.  All  that  is  necessary  is  the  microscopical 
examination  of  a  stained  film  of  the  pus.  It  is,  however, 
to  be  remembered  that  the  gonococci  are  not  evenly  dis- 
tributed throughout  the  pus  ;  therefore  several  films  should 
be  prepared,  and  no  antiseptic  injection  should  have  been 
made  for  some  hours  prior  to  the  examination.  SiiouUl 
no  gonococci  be  found  on  the  first  examination,  the  search 
should  be  repeated  on  the  following  day,  when,  if  they 
are  still  absent,  it  may  be  safely  concluded  that  the  case  is 
not  one  of  gonorrhoea.  Thh,  hoivcvcr,  applies  only  to  acute 
urethritis.  In  the  chronic  condition  the  gonococci  are 
met  with  in  sparing  numbers,  and  may  be  entirely  absent 
from  the  secretion  for  days  together.  Moreover,  their 
appearance  is  by  no  means  so  characteristic  as  in  the 
acute  stage,  for  the  cocci  are  no  longer  found  within  the 
body  of  the  pus  cells,  but  free,  or  adhering  to  the  surface 
of  epithelial  cells.  Hence  their  detection  may  require 
considerable  bacteriological  experience. 

Should  cocci  be  detected  in  the  secretion,  it  is  seldom 
difficult  to  pronounce  positively  whether  they  are  or  are 
not  gonococci.  The  chief  points  on  which  this  diagnosis 
is  based  are  the  following  : 

(a)  The  presence  of  a  kidney-shaped  diplococcus  in 
groups  of  four  or  multiples  of  four  ; 

(b)  The  situation  of  the  coccus  within  the  body  of  the 
pus  cell ; 

(c)  The  non-retention  by  the  coccus  of  Gram's  stain  ; 
and 

{d)  The  failure  of  the  coccus  to  grow  on  ordinary 
gelatine  or  agar. 

A  point  of  considerable  medico-legal  and  social  im- 
portance is  the  fact  that  the  gonococcus  may  retain  its 


Bacteriological  Diagnosis  of  Gonorrhoea      t,;^ 

vitality  for  some  considerable  time  in  jjiis,  ffjr  llK;iir;li  tlie 
gonococcus  has  but  little  power  of  resistance  against 
heat,  dryness,  or  antiseptics,  it  may  nevertheless  live  for 
several  days  in  the  thick  purulent  secretion.* 

*  lleiman,  Nc^u  York  Mcdicdl  Record.,  June,  1895,  and  December, 
1896. 


CHAPTER   \I 

THE  MORBID  CHANGES  IN  THE  URETHRAL  SECRETION 
AND  MUCOUS  MEMBRANE 

It  may  be  remarked  that  the  nature  and  amount  of  a 
urethral  secretion  is  generally  better  appreciated  b}-  an 
examination  of  the  urine  than  by  inspecting  the  secretion 
as  it  exudes  from  the  meatus.  This  especially  applies  to 
the  chronic  condition  of  the  disease  ;  indeed,  as  we  shall 
see  later,  it  often  happens  that  the  only  sign  of  a  chronic 
urethritis  is  the  appearance  of  the  urine,  Moreo\'er,  by 
the  means  suggested  we  are  enabled  to  ascertain  whether 
it  is  a  case  of  gonorrhoea  or  not  without  the  patient  being 
asked  a  single  question  or  being  a\\are  of  our  suspicion. 
The  importance  of  this  when  dealing  with  women  or  with 
men  of  a  sensitive  nature  will  be  readily  appreciated.  In 
the  earliest  stage  of  the  disease,  if  the  urine  (and  preferably 
the  morning  urine,  for  reasons  which  haxe  been  explained) 
be  passed  into  a  conical  urinary  glass,  it  will  be  noticed 
that  floating  in  the  clear  fluid  there  are  a  few  gelatinous 
thread-like  bodies,  which,  if  examined  \\ith  the  microscope, 
are  seen  to  be  composed  of  pus  and  epithelial  cells,  held 
together  by  mucin.  They  arc  formed  by  the  urinary 
stream  detaching  and  rolling  up  the  thin  tenacious  secre- 
tion jiroduccd  b\-  the  inflamed  mucous  membrane.  These 
filaments  are  known  as  *  urethral  threads.' 

As  the  disease  advances  the  urine  will  no  longer  appear 
■      34 


I 


Morbid  Changes  in  the  Urethral  Secretion    35 

clear,  l)iit  cloudy,  frf)in  the  j)rcscnco  of  muciis.  The 
cloudiness  then  j:,dves  place  to  a  inilk}'  turhidity,  due  to 
the  increasing  number  of  pus  cells  present.  If  the  urine 
be  allowed  to  stand  a  few  minutes  the  pus  cells  will  sink 
to  the  bottom  of  the  glass,  forming  a  thick  creamy  sedi- 
ment, over  which  will  be  seen  a  light  cloudy  deposit  of 
mucus.  In  the  further  progress  of  the  disease  the  layer 
of  pus  increases  in  amount,  whilst  the  mucus  diminishes. 
When  the  disease  has  reached  its  acme  little  but  pus  is 
seen.  As  the  disease  abates,  all  these  conditions  are 
reproduced  in  an  inverse  order.  First  the  pus  layer 
gradually  diminishes  in  quantity,  the  mucus  proportion- 
ately increasing  ;  the  mucus  then  disappears,  and  in  the 
clear  urine  the  urethral  threads  are  seen  floating  ;  finally 
these  disappear,  and  the  disease  is  at  an  end. 

Much  useful  information  may  be  obtained  from  a  care- 
ful microscopical  examination  of  the  secretion,  apart  from 
the  question  as  to  the  presence  or  absence  of  the  gono- 
coccus.  If  the  secretion  be  examined  in  the  earliest  stages 
of  the  disease,  it  will  be  noticed  that  the  principal  cells 
present  are  not  leucocytes,  but  large  squamous  epithelial 
cells ;  gonococci  are  numerous,  and  are  met  with  both 
free  and  in  the  pus  cells  (Fig.  8).  As  the  inflammation 
increases  in  severity,  the  leucocytes  and  gonococci  become 
more  and  more  numerous,  the  epithelial  cells  being  less 
frequently  seen.  The  pus  cells  then  become  crowded  with 
the  cocci  and  gradually  degenerate.  When  the  acme  of 
the  disease  is  over  and  the  pus  changes  to  a  muco-purulent 
secretion,  it  will  be  found  that  the  epithelial  cells  reappear 
again  mingled  with  the  leucocytes.  The  gonococci  are 
still  present,  both  free  and  in  the  pus  cells,  though  in 
smaller  numbers ;  but  they  are  not  seen  within  the 
epithelial  cells,  though  often  covering  their  surface. 

In  the  latest  stage  of  the  disease  both  the  leucocvtes 


36       Treatment  of  Gonorrhoea  in  the  Male 

and  gonococci  are  met  with  but  sparingly,  the  urethral 
threads  showing  the  presence  of  transitional  epithelial 
cells,  with  few  pus  cells  and  cocci.  An  attempt  has  been 
made  to  found  the  prognosis  upon  the  relation  of  the 
gonococci  to  the  leucocytes,  It  was  thought  that  the 
finding  of  many  extracellular  cocci  was  of  evil  import, 
betokening  a  specially  severe  attack  ;  and,  on  the  other 
hand,  that  where  the  cocci  were  largely  or  wholly  intra- 
cellular   the     prognosis     was     particularly     favourable.* 


m      :i^y 

.,  *  \ 

.13; 

■v^(«] 

,,  ^'*> 

Fig.  8. — Urethral  Secretion  in  the  1-1arliest  Stage  of 
Acute  Gonorrhcea.     (x  1,000.) 

Lan^t  has,  however,  shown  that  the  position  of  the  cocci 

depends  upon  the  manner  in  which  the  pus  is  obtained. 

If  it  flow  freely  out  of  the  urethra,  most  of  the  cocci  are 

within  the  leucocytes  ;    but  if  the  last  drops  of  pus  be 

squeezed   out    of  the    urethra   by   firm    pressure,    or   are 

removed  by  scraping  the  mucous   membrane,   they  then 

always  contain  large  numbers  of  extra-cellular  cocci.  This 

accords  with  my  own  observations. 

The  position  of  the  gonococci  with  respect  to  the  leuco- 

*  Podrcs,  1885  ;  Drobny,  1898. 

t  Lanz,  Arc/i./ur  Dcniuitologic  uiui  Syphilis^  IJd.  52. 


Morbid  Changes  in  the  Urethral  Secretion     ;\y 

cytes  would  seem,  therefore,  to  have  no  importance  in 
prof^nosis,  though  it  may  be  remarked  that  the  presence 
of  a  large  number  of  leucocytes  and  gonococci  betokens  a 
virulent  infection,  and  therefore  is  an  unfavourable  sign  ; 
but  w^here  few  cocci  and  pus  cells  are  seen,  it  may  be  sur- 
mised that  the  infection  is  mild  and  the  course  likely  to 
be  favourable.  But  before  any  such  conclusion  is  drawn  it 
is  essential  that  a  considerable  number  of  stained  films  be 
examined. 

Eosinophile  Cells.— If  the  films  of  pus,  after  being 
stained  with  methylene  blue,  be  counter  -  stained  with 
eosin — a  method  which  has  much  to  recommend  it — it 
will  be  found  that,  whilst  the  cocci  and  nuclei  of  the  pus 
cells  are  coloured  blue,  the  protoplasm  of  the  latter  is 
faintly  tinged  pink  by  the  eosin.  On  close  examination  it 
will  be  seen  that  the  granules  of  some  of  the  leucocytes 
are  deeply  stained  with  eosin.  Those  cells  the  granules 
of  which  have  a  special  avidity  for  eosin  have  been  termed 
'  eosinophile  '  cells. 

It  is  asserted  that  where  the  posterior  urethra  is 
affected — i.e.,  where  the  inflammation  is  of  a  more  virulent 
type^these  eosinophile  cells  are  markedly  increased  in 
number,  and  therefore  are  to  be  regarded  as  of  unfavourable 
import.*  But  my  observations  upon  this  point  do  not 
lead  me  to  confirm  this  statement.  I  propose,  however, 
to  discuss  the  question  subsequently. 

It  may  be  convenient  here  to  note  briefl}-  the  changes 
that  take  place  in  the  urethral  mucous  membrane  in  the 
progress  of  the  disorder.  As  is  well  known,  the  male 
urethra  is  lined  with  stratified  epithelium,  the  superficial 
cells  of  which  are  cylindrical,  save  at  the  meatus  and  in 

'•'  Bettman,  ArcJi.  fiir  Dei-iiiatologic  und  Syphilis,  Bd.  39;  Mumch. 
mcd.  WocJi.,  1898;  Finger,  '  Die  Blennorrhos  de  Sexualorgane,'  1905, 
pp.  93  and  94  ;  Pezzoli,  Arch,  fit r  Dcniiaiologic  iind  Syphilis,  Bd.  35. 


3^       Treatment  cf  Gonorrhoea  in  the  Male 

the  fossa  navicuhiris,  where  the\-  are  squamous.  Outside 
the  mucous  membrane  there  is  a  layer  of  subepithehal 
connective  tissue  in  which  run  numerous  bloodvessels, 
and  external  to  that  a  layer  of  involuntary  muscular  fibres, 
separating  the  former  layer  from  the  proper  substance  of 
the  spongy  bod}-. 

The  mucous  membrane  of  the  urethra  is  furnished 
throughout,  except  just  at  the  meatus,  with  numerous 
small  acinous  mucous  glands  and  follicles,  which  are 
called  the  glands  of  Littre.  The  ducts  of  these  glands 
open  either  directly  on  to  the  surface  of  the  mucous 
membrane  or  into  the  lumen  of  the  lacunae  of  Morgagni. 
These  lacunse  are  small  recesses  in  the  mucous  membrane, 
which  open  by  oblique  orifices  pointing  forwards.  They 
are  met  with  almost  wholly  in  the  upper  wall  of  the  penile 
urethra,  and  are  from  fifteen  to  twenty  in  number.  The 
orifice  of  a  lacuna  is  just  large  enough  to  occasionally 
catch  the  point  of  a  fine  catheter. 

The  stratified  squamous  epithelium  in  the  fossa  navicu- 
laris  seems  to  offer  a  certain  resistance  to  the  gonococci, 
for  they  are  only  met  with  on  the  surface  of  the  epi- 
thelium. In  other  parts  of  the  urethra  the  cocci  rapidly 
penetrate  by  the  interepithelial  spaces  to  the  deeper  cells 
of  the  epithelium  and  to  the  connective  tissue  beneath. 
In  consequence  of  this  invasion  the  epithelial  cells  become 
loosened,  undergo  mucoid  degeneration,  and  are  thrown 
off.  The  toxine  produced  by  the  micro-organism  irritates 
and  inflames  the  mucous  membrane  of  the  urethra,  the 
bloodvessels  dilate,  and  through  their  walls  a  constant 
stream  of  serum  and  leucocytes  passes  towards  the  surface. 
Thus  at  this  stage  there  are  two  opposite  streams — one  of 
cocci,  making  their  way  from  the  surface  to  the  subepi- 
thelial tissue,  and  another  of  serum  and  leucocytes, 
passing    from    the    deeper    layers  towards   the    surface. 


Morbid  Changes  in  the  Urethral  Secretion     yj 

The  gonococci  are  taken  up  by  the  leucocytes ;  but,  not- 
withstanding much  study  of  the  subject,  the  relation 
of  the  gonococci  to  the  leucocytes  is  still  obscure.     It 

is  uncertain  whether  the  cocci  invade  the  passive  pus 
cells  or  are  attacked  by  the  leucocytes,  as  suggested  by 
Metschnikoff.  The  latter  seems  the  more  probable,  but  it 
is  strange  that  the  cocci  do  not  appear  to  be  adversely 
affected  by  their  situation  within  their  host.  They  appar- 
ently undergo  no  change,  either  morphologically  or  bio- 
logically. It  is  indeed  believed  by  Bumm,  Henke,  and 
others  that  the  gonococci  multiply  within  the  cell-body. 
If  this  were  so,  we  should  expect  the  leucocytes  to  show 
signs  of  degeneration  ;  but  they  do  not.  As  the  leucocytes 
make  their  way  towards  the  surface  they  convey  the  cocci 
from  the  deeper  parts.  Thus  the  penetration  of  the  cocci 
towards  the  deeper  structures  is  actively  resisted  by  the 
stream  of  leucocytes  passing  outwards,  in  consequence  of 
which,  after  a  longer  or  shorter  time,  all  the  cocci  are 
removed  from  the  deeper  parts. 

According  to  Finger,  to  whom  we  are  indebted  for 
much  of  our  knowledge  on  this  subject,  this  normally 
occurs  at  or  about  the  third  week.  When  this  is  accom- 
plished the  acutest  stage  of  the  disease  is  passed,  and  the 
inflammation  begins  to  subside.  The  denuded  epithelium 
commences  to  degenerate,  and  at  the  same  time  undergoes 
a  curious  metaplasia,  a  stratified  squamous  epithelium 
being  developed  in  place  of  the  columnar  epithelium.  The 
gonococci  are  now  found  only  on  the  surface  of  the  epi- 
thelium, where  they  continue  to  irritate  and  inflame  the 
membrane  ;  but  should  the  disease  run  a  favourable  course, 
the  number  of  cocci  steadily  diminishes  and  the  inflamma- 
tion subsides.  Frequenth',  however,  the  favourable  course 
of  the  disease  is  interrupted  by  an  exacerbation  of  the 
inflammation,  provoked,  perhaps,  by  some  indiscretion  in 


40       Treatment  of  Gonorrhoea  in  the  Male 

food,  more  especially  in  the  use  of  alcohol,  or  by  sexual 
excitement,  causing  an  acute  hyperccmia  of  the  mucous 
membrane.  The  h\perjemia  produces  a  greatly  increased 
flow  of  serum  and  migration  of  leucocytes  ;  the  epithelium 
is  loosened  and  detached,  and  through  the  cell  spaces 
the  gonococci  again  penetrate,  to  pro\oke  afresh  all  the 
symptoms  of  the  acutest  stage. 

Such  relapses  may  occur  again  and  again,  but  each 
time  the  reaction  diminishes.  The  mucous  membrane 
gradually  becomes  indifferent  to  the  toxine,  and  responds 
less  and  less  to  its  stimulus.  The  consequence  is  that, 
after  several  repetitions  of  this  process,  the  reaction  is 
insufficient  to  eliminate  all  the  cocci  from  the  deeper 
parts  of  the  membrane,  and  those  cocci  which  are  left  in 
the  deeper  layers  of  the  mucous  membrane  produce  a 
slight,  but  constant,  irritation,  which  provokes  a  prolifera- 
tion of  the  connective-tissue  cells,  forming  the  so-called 
small-celled  infiltration.  This  proliferation  of  the  con- 
nective-tissue cells  marks  the  onset  of  the  chronic  stage. 

It  is  of  much  practical  importance  to  observe  that  the 
inflammation,  even  in  its  acutest  stages,  does  not  affect 
equally  all  portions  of  the  mucous  membrane.  It  is  in 
and  around  the  various  mucous  glands  of  the  urethra  that 
the  inflammation  is  the  acutest,  and  it  is  there  that  it 
lingers  long  after  the  other  parts  have  recovered. 


CHAPTER  VII 

THE  TREATMENT  OF  ACUTE  URETHRITIS 

Notwithstanding  the  interest  which  the  disease  has 
always  awakened,  evidenced  by  the  extended  literature 
on  the  subject,  there  is  perhaps  hardly  any  disorder 
treated  so  empirically  and  irrationally.  How  frequently 
the  surgeon,  armed  with  one  or  two  favourite  injection 
formulae,  prescribes  them  forthwith  to  the  unfortunate 
patient,  irrespective  of  the  nature  of  the  urethritis,  the 
stage  of  the  disease,  the  extent  of  the  mucous  membrane 
involved,  and  the  presence  or  absence  of  complications  ! 
It  is  little  to  be  wondered  at  that  so  blind  a  shot  should  so 
frequently  miss.  In  order  to  treat  the  disease  rationally, 
it  is  necessary  to  determine — (a)  whether  it  is  a  case  of 
gonorrhcea  or  pseudo  -  gonorrhcea  ;  (6)  the  stage  of  the 
disorder  ;  (c)  the  extent  to  which  the  mucous  membrane 
is  affected ;  and  (d)  the  presence  or  absence  of  complica- 
tions. It  is  only  when  all  these  particulars  have  been 
ascertained  that  one  is  in  a  position  to  prescribe  for  the 
patient  with  precision. 

The  treatment  of  gonorrhoea  maj'  be  conveniently 
discussed  under  three  heads :  (i)  Diet  and  hygiene ; 
(2)  internal  remedies  ;  (3)  local  applications. 

I.  Dietetic  and  Hygienic  Measures. — The  importance 
of  this  part  of  the  treatment  is  so  full}-  recognised  that  it 
is  unnecessary  to  dwell  upon  it  at  an}-  length.    Experience 

41 


4-        Treatment  of  Gonorrhoea  in  the  Male 

has  abundantly  proved  the  necessity  of  so  regulating  the 
patient's  habits  as  to  obtain  the  greatest  amount  of  rest 
for  the  parts  concerned,  and  the  avoidance  of  frequent 
changes  in  the  local  blood  supply.  Everything  which  is 
likely  to  even  temporarily  increase  the  hyperemia  of  the 
urethra  is  to  be  as  far  as  possible  avoided.  It  is  with  this 
object  in  view  that  the  patient  is  placed  on  a  light  and 
easily-digested  diet,  and  forbidden  to  take  alcohol  in  any 
form,  or  to  indulge  in  violent  exercises,  such  as  riding, 
cycling,  etc.  He  must  be  also  warned  that  the  slightest 
sexual  excitement  is  in  the  highest  degree  injurious,  and 
is  a  frequent  cause  of  retarded  recovery.  And  energetic 
measures  must  be  taken  if  necessary  to  combat  the 
tendency  to  protracted  erections  and  nocturnal  seminal 
emissions. 

The  patient  must  be  instructed  to  rest  as  much  as 
possible.  It  should  be  clearly  pointed  out  to  him  that 
the  disease,  so  far  from  being  the  trivial  malady  it  is 
commonly  supposed  to  be,  is  a  most  serious  disorder  in 
itself,  and  is  liable  to  still  more  serious  complications, 
which  it  is  of  the  utmost  importance  to  avoid.  It  cannot 
be  too  strongly  urged  upon  him  that  the  most  effective 
way  of  avoiding  these  complications  is  for  him  to  remain 
in  bed  during  the  early  stages  of  the  disease.  It  is  to  be 
regretted  that  this  complete  rest  in  bed  is  not  more 
frequently  enjoined,  for  there  is,  I  believe,  no  measure 
that  can  be  prescribed  more  efficacious  in  shortening  the 
duration  of  the  disease,  and  avoiding  its  to-be-dreaded 
complications.  It  is  true  that  often  the  desire  to  keep 
secret  the  nature  of  the  disease  makes  it  difficult  to  follow 
this  advice ;  but  when  its  importance  is  appreciated  the 
difficulties  can  be  generalh'  circumvented. 

Where  it  is  impossible  for  the  patient  to  remain  in  bed, 
the  genitals  should  be  supported   by   a  well -fitting  sus- 


The  Treatment  of  Acute  Urethritis         43 

pensory  bandage;,  care  Inking  taken  thai  the  same  does  ikjI 
press  undidy  upon  the  penis  or  i)erineun"i.  Some  arrange- 
ment should  be  contrived  for  the  absorption  of  the  free 
purulent  urethral  discharge.  It  is  not  a  good  plan  to 
insert  cotton-wool  under  the  prepuce,  as  is  so  frerjnently 
advised,  it  being  apt  to  hinder  the  free  flow  of  the  pus.  A 
better  method  is  to  place  the  penis  in  a  little  al)sorbent 
wool  bag,  such  as  is  supplied  by  Hartmann's  Wood-wool 
Company. 

2.  Internal  Remedies.  —  Although  numerous  drugs 
have  been  advocated  from  time  to  time  as  of  value  in  the 
treatment  of  this  disease,  there  are  remarkably  few  which 
have  stood  the  test  of  time.  Almost  the  only  remedies 
which  have  proved  themselves  of  decided  value  are  certain 
of  the  balsams,  of  which  many  kinds  are  used  ;  but  of  all 
of  these  sandal-wood  oil  is  the  best.  Copaiva,  which  is 
also  largely  used,  possesses  no  advantages,  and  it  is 
decidedly  irritating  to  the  stomach  and  kidneys.  Although 
there  is  no  doubt  as  to  the  value  of  these  balsams,  they 
rarely  seem  able  to  completely  cure  the  disease,  and  are 
accordingly  to  be  used  only  as  adjuncts  to  the  local  treat- 
ment. They  should  be  given  in  the  earliest  stage  of  the 
disorder.  They  are  of  special  value  in  those  florid  cases 
where  all  local  treatment  is  contra-indicated  by  reason  of 
the  presence  of  pain  and  irritation.  These  balsamic 
remedies  when  taken  by  the  mouth  are  excreted  more  or 
less  unchanged  in  the  urine,  and  act  as  a  local  stimulant 
and  antiseptic  to  the  inflamed  mucous  membrane.  Uro- 
tropin,  from  which  much  was  at  one  time  hoped,  has  not 
proved  of  signal  value  in  pure  gonorrhoeal  urethritis,  but 
it  may  be  used  with  advantage  in  certain  cases  of  mixed 
infection  of  both  bladder  and  urethra. 

3.  Local  Applications.  —  Local  remedies  have  always 
played  a  large  part  in  the  treatment  of  urethritis,  and 


44       Treatment  of  Gonorrhoea  in  the  Male 

more  especially  since  the  microbic  origin  of  the  disease 
was  determined ;  and  there  can  be  no  question  that  the 
application  of  remedies  directly  to  the  affected  part  is 
both  rational  and  highly  successful  ;  for  though  by  means 
of  dietetic  and  hygienic  measures  and  the  administration 
of  balsams  the  disease  can  be  greatly  modified,  yet  these 
measures  are  rarely  sufficient,  apart  from  local  applications, 
to  bring  about  a  complete  cure. 

Notwithstanding  the  number  of  local  remedies  now  in 
use  is  very  great,  and  is  being  continually  increased,  yet  it 
must  be  regretfully  acknowledged  that  up  to  the  present 
time  no  panacea  for  this  disease  has  been  discovered. 
Some  of  the  newer  remedies,  as  we  shall  see,  are  of  great 
value,  and  offer  certain  advantages  over  the  earlier  ones. 
But  they  all  fall  far  short  of  fulfilling  the  requirements  of 
a  specific  remedy  for  all  stages  of  the  disease. 

In  estimating  the  value  of  a  remedy  the  following  facts 
should  be  borne  in  mind  :  (a)  That  gonorrhcea,  like  most 
diseases  in  the  absence  of  aggravating  circumstances, 
naturally  tends  to  recovery ;  (b)  that  almost  all  the  local 
remedies  in  use  are  of  an  astringent  character,  and  there- 
fore arrest  the  secretion  of  the  pus,  leading  the  patient  to 
suppose  himself  cured ;  and  (c)  that  very  close  observation 
is  required  in  order  to  determine  that  a  cure  has  been 
effected. 

The  ideal  remedy  should  fulfil  the  following  conditions  : 
(a)  It  must  be  able  rapidly  to  destroy  or  remove  the  virus, 
the  gonococcus ;  {b)  it  must  do  this  without  injuring  the 
mucous  membrane  ;  and  (c)  it  must  alia}-  the  existing 
inflammation.  It  might  be  supposed  that  from  the  large 
number  of  known  antiseptics  it  would  be  easy  to  find 
several  that  would  fulfil  these  requirements.  Such  suppo- 
sition, however,  is  baseless.  The  majority  of  the  anti- 
septics that  are  capable  of  destroying  the  micro-organisms 


The  Treatment  of  Acute  Urethritis         45 

are  distinctly  irritating  tcj  the  tissues,  and  would  thereby 
contravene  the  second  condition  reqiiir(.(l.  /\g:iin,  too 
much  must  not  be  expected  from  the  action  of  antiseptics. 
For  it  is  to  be  remembered  that  the  cocci  arc  to  a  great 
extent  situated  in  and  below  the  mucous  membrane,  and 
are  especially  hidden  in  the  numerous  crypts  and  follicles 
of  the  urethra  in  situations  where  it  is  impossible  for  the 
antiseptic  iiuid  to  reach  them.  Now,  although  many  of 
the  antiseptics  in  common  use  are  able,  even  in  dilute 
solutions,  readily  to  destroy  the  gonococcus  when  brought 
directly  into  contact  with  it,  yet  otherwise  they  are 
powerless  to  affect  it. 

Again,  almost  all  the  antiseptics  have  the  property  of 
causing  a  coagulation  of  the  albumen  they  may  come  into 
contact  with.  This  seriously  impairs  their  efficiency,  for 
it  both  prevents  the  penetration  of  the  antiseptics  into  the 
deeper  tissues,  and  it  naturally  diminishes  the  bactericidal 
property  of  the  chemical.  Deductions  drawn  from  labora- 
tory experiments  on  the  efficiency  of  antiseptics  in  de- 
stroying micro-organisms  are  apt  to  prove  most  fallacious 
when  applied  clinically. 

It  is  highly  probable  that  the  beneficial  effects  of  anti- 
septic urethral  injections  are  due  far  less  to  the  bactericidal 
action  of  the  chemical  than  to  its  power  of  inhibiting  the 
development  of  the  micro-organisms  by  so  affecting  the 
mucous  membrane  as  to  render  it  a  less  favourable  medium 
for  the  growth  of  the  coccus. 

If  from  the  mass  of  suggested  remedies  we  select  those 
which  have  proved  themselves  to  be  of  value,  we  shall  find 
the  list  to  be  surprisingly  small.  Chief  and  foremost  must 
be  mentioned  the  old  remedy,  nitrate  of  silver.  This  is 
one  of  the  most  trustworthy  of  local  applications.  Un- 
fortunately it  is  ver}'  irritating,  even  in  dilute  solutions  ; 
besides  which  it  is  readily  decomposed  by  the  chlorides 


46       Treatment  of  Gonorrhoea  in  the  Male 

present  in  the  pus.  Recently  a  number  of  combinations 
of  this  salt  with  various  albuminous  bodies  have  been 
placed  on  the  market,  several  of  which  have  proved  to  be 
valuable.  The  great  advantage  of  these  combinations  is 
that  they  cause  little  or  no  pain  or  irritation  when  in- 
jected, and  are  not  decomposed  by  the  pus.  Moreover, 
as  they  do  not  cause  a  coagulation  of  the  albumin,  they 
seem  able  to  penetrate  somewhat  deeper  into  the  tissues 
than  pure  nitrate  of  silver. 

The  earliest  of  these  preparations,  argentamin  and 
argonin,  proved  to  be  unstable ;  but  the  more  recent 
compounds,  protargol,  largin,  and  argyrol,  are  free  from 
this  defect, 

Ne.xt  to  nitrate  of  silver  and  its  compounds  in  order  of 
value  are  solutions  of  permanganate  of  potash,  sulphate  of 
thallin,  sulphate  of  zinc,  and  sulphate  of  copper. 

It  is  conveiiient  clinicall}'  to  divide  these  local  applica- 
tions into  three  groups — namely,  those  which  are  pure 
antiseptics,  as  protargol,  largin,  and  sulphate  of  thallin  ; 
those  which  are  both  antiseptic  and  astringent,  as  nitrate 
of  silver ;  and  those  which  are  simply  astringent,  as 
sulphate  of  zinc. 

The  above  classification  is  important,  for  the  character 
of  the  remedy  must  be  suited  to  the  existing  stage  of  the 
disease  present.  In  the  early  and  very  acute  stage  we 
must  be  careful  that  the  local  remedy  has  but  slight 
astringent  properties,  or  otherwise  it  will,  by  diminishing 
the  hypersemia  of  the  tissues,  check  the  migration  of  the 
leucocytes,  and  so  hinder  the  elimination  of  the  gonococci 
from  the  deeper  structures.  Nor  must  the  injection  fluid 
at  this  stage  be  of  an  irritating  nature.  However  power- 
ful the  antiseptic  properties  of  the  fluid  may  be,  it  is 
counter-indicated  if  it  causes  irritation,  and  so  increases 
the  inflammation.     The  cocci  grow  more  readily    in    an 


The  Treatment  of  Acute  Urethritis         47 

inflamed  mucous  memljianc  tli.LU  in  ,'i  non  -  inllumcd 
tissue.  Hence,  as  lon^;  as  there  are  signs  of  acute  inl];i.in- 
mation  present,  it  must  on  no  account  be  increased  by  an 
irritating  lotion. 

The  fluid  selected  must  be  an  antiseptic  which  is  un- 
irritating,  and  as  free  from  astringent  properties  as  possible. 
The  remedies  which  most  nearly  fulfil  these  conditions 
are  solutions  of  protargol  {~\  to  i  per  cent.),  largin  (}^  to 
I  per  cent.),  argyrol  (i  to  2  per  cent.),  sulphate  of  thallin 
(I  per  cent.),  and  permanganate  of  potash  (i  in  10,000). 
These  are  the  fluids  best  suited  for  the  treatment  of  the 
disease  in  the  acute  inflammatory  stage.  They  all  possess 
antiseptic  properties — the  two  latter,  it  is  true,  only  in  a 
slight  degree ;  they  produce  neither  pain  nor  irritation  when 
introduced  into  the  urethra,  and  as  they  do  not  cause  a 
coagulation  of  the  albumin,  they  are  capable  of  a  certain 
power  of  penetration. 

As  these  fluids  are  non-irritating,  the  injection  can  be 
retained  in  the  urethra  for  a  considerable  time  without 
discomfort.  Moreover — and  this  is  an  important  point — 
as  they  have  no  irritating  action,  they  do  not  cause  a 
spasm  of  the  compressor  urethras,  and  so  it  is  possible  to 
inject  the  fluid  into  the  posterior  urethra  by  means  of  an 
ordinary  syringe.  This  it  is  not  possible  to  do  if  marked 
astringent  solutions  are  used. 

Injections  of  these  bland  fluids  should  be  continued 
until  the  disease  enters  on  the  second  stage,  which  clini- 
cally is  recognised  by  the  purulent  discharge  becoming 
thinner  and  more  mucoid,  and  by  the  disappearance  of  the 
pain  on  micturition.  There  is  now  no  longer  any  reason 
why  astringent  remedies  should  be  avoided.  The  cocci 
having  been  eliminated  from  the  deeper  tissues,  our  object 
now  is  to  destroy  such  cocci  as  are  growing  on  the  surface 
of  the  epithelium,  and  to  alia}-  the  inflammation  they  have 


4^^      Treatment  of  Gonorrhoea  in  the  Male 

evoked.  This  will  be  best  done  by  applyinj;  one  of  the 
astringent  antiseptics,  such  as  dilute  solutions  of  nitrate  of 
silver  (i  in  10,000)  or  permanganate  of  potash  (i  in  8,000). 
When  the  gonococci  have  completely  disappeared  from 
the  secretion,  and  the  disease  has  entered  upon  its  last 
stage,  the  pure  astringents,  such  as  sulphate  of  zinc  and 
alum,  may  with  advantage  be  used  to  allay  the  existing 
hyperiemia  and  complete  the  cure. 

Such  are  in  general  the  lines  on  which  the  local  treat- 
ment of  acute  gonorrhoea  is  based.  It  will  be  convenient 
to  consider  the  details  of  the  treatment  under  two  heads, 
viz.  :  (i)  When  the  disease  affects  the  anterior  urethra 
only  ;  and  (2)  when  it  affects  the  posterior  urethra. 


CHAPTER  VIII 

THE  TREATMENT  OF  ACUTE  ANTERIOR  URETHRITIS 

Although  it  is  unusual  for  a  hospital  patient  to  apply  for 
treatment  until  the  discharge  is  copious  and  the  disease 
fairly  advanced,  it  not  infrequently  happens  that  the  more 
intelligent  private  patient  seeks  medical  aid  at  the  first  sign 
of  the  disorder,  even  directly  after  exposure  to  infection. 
In  such  a  case  the  surgeon  may  feel  tempted  to  try  and 
cut  short  the  malady  by  the  application  of  some  strong 
antiseptic  remedy.  This  so-called  '  abortive  treatment ' 
has  received  much  attention,  and  every  few  years  its  use 
has  been  revived  ;  yet  it  must  be  confessed  that  there  is 
little  to  be  said  in  its  favour,  either  from  a  theoretical  or 
from  a  practical  point  of  view.  We  have  alread}-  seen 
that  the  gonococci  within  even  a  few  hours  of  the  inocula- 
tion penetrate  between  the  epithelial  cells  to  the  deeper 
parts  of  the  urethral  mucous  membrane,  in  which  situation 
they  are  effectually  protected  from  the  strongest  antiseptics 
that  can  be  applied.  Moreover,  the  use  of  these  strong 
antiseptics  induces  a  violent  inflammatory  reaction,  which 
is  likely  greatly  to  aggravate  the  disorder.  For  these 
reasons  the  use  of  abortive  remedies  has  been  to  a  large 
extent  abandoned. 

It  might,  however,  be  well  to  mention  the  method 
advocated  by  Janet,  one  of  the  latest  of  this  class  of 
remedies,  which  has  found  a  certain  amount  of  favour. 

49  4 


so      Treatment  of  Gonorrhoea  in  the  Male 

As  soon  as  the  presence  of  the  disorder  is  diagnosed,  thr 
whole  of  the  urethra  is  irrigated  with  a  warm  sohition  of 
permanganate  of  potash  (i  in  2,000).  Five  hours  later  the 
anterior  urethra  ouly  is  irrigated  with  a  stronger  solution 
(I  in  1,500^,  and  after  a  father  inter\al  of  li\e  hours  with 
one  still  stronger  (i  in  1,000).  For  the  following  four  or 
five  days  irrigations  are  repeated  every  twelve  hours  with 
the  weaker  solution  (i  in  2,000).  But  it  is  difficult  to 
carr}-  out  this  method  in  ordinary  practice,  and  it  is  b\-  no 
means  certain  in  its  results  ;  while  it  frequently  causes 
much  pain  and  cedema,  and  greatly  aggravates  the  ailment. 

The  only  time  when  the  abortive  treatment  is  likely  to 
prove  successful  is  on  tiiose  rare  occasions  when  the 
patient  seeks  medical  advice  immediately  after  exposure  to 
infection.  As  the  gonococci  are  then  probably  merely 
lying  on  the  surface  of  stratified  epithelium  lining  the 
fossa  na\-icularis,  the  introduction  of  an  antiseptic  fluid  at 
this  period  may  reasonably'  be  expected  to  destroy  the 
specific  virus,  and  so  prevent  the  development  of  the 
disease.  On  the  Continent  this  prophylactic  treatment 
has  been  largely  adopted,  and  appears  to  have  a  consider- 
able measure  of  success.  For  this  purpose  a  few  drops  of 
either  a  2  per  cent,  solution  of  nitrate  of  silver,  or  a  20  per 
cent,  solution  of  protargol,  are  introduced  into  the  meatus 
immediately  after  exposure  to  infection. 

Although,  as  a  rule,  we  may^  with  advantage  at  once 
apply  local  remedies  in  the  acute  stage  of  the  disorder, 
there  are  two  conditions  which  contra-indicate  this  treat- 
ment. The  first  of  these  is  an  exceptionally  acute  in- 
flammation, as  evidenced  by  much  cedema  of  the  penis 
and  prepuce,  excessive  chordee.  and  blood-stained  secre- 
tion. The  other  is  the  presence  of  a  complication  such 
as  epididymitis.  In  such  circumstances  all  local  applica- 
tions must  be  postponed   until  the  most  acute  symptoms 


Treatment  of  Acute  Anterior  Urethritis      5  i 

have    subsided,    the   treatment    l;ein;^^  conriM(;d   to   consti- 
tutional and  hyf:(i(;nic  remedies. 

In  the  majority  of  cases  local  treatment  by  injection 
may  be  at  once  begun.  As  the  patient  will  have  to  do 
this  himself,  it  is  absolutely  necessary  to  ex])lain  carefull}' 
to  him  exactly  how  the  injection  is  to  be  made,  or  it  will 
almost  certainly  be  imperfectly  done,  and  consequently 
little  or  no  benefit  will  be  obtained.  The  best  instrument 
for  the  purpose  is  some  form  of  syringe.  In  certain  con- 
ditions, as  we  shall  see,  the  application  is  better  made  by 
means  of  an  irrigator,  but  for  ordinary  purposes  the 
syringe  is  to  be  preferred.  Care,  however,  should  be 
taken  to  secure  the  best  form  of  syringe.  The  ordinary 
glass  gonorrhoea]  syringe  is  almost  valueless;  the  piston 
rarely  works  well,  the  nozzle  is  far  too  slender,  and,  as 
the  capacity  of  these  instruments  varies  greatly-,  it  is  a 
mere  chance  whether  the  patient  will  obtain  one  holding 
2  ounces  or  only  J-  ounce  of  liquid.  A  syringe  is  needed 
the  piston  of  which  works  smoothly  and  accurately  ;  it 
should  be  fitted  with  a  large  conical  nozzle,  which,  when 
inserted  into  the  meatus,  effectually  plugs  it,  and  so 
prevents  the  escape  of  the  fluid.  The  instrument  must 
be  large  enough  to  contain  sufficient  fluid  to  complete!}' 
distend  the  urethra,  so  that  all  the  folds  in  the  mucous 
membrane  may  be  obliterated,  and  the  fluid  brought  into 
contact  with  every  portion  of  it.  A  good  form  of  SNTinge 
is  depicted  in  Fig.  9.  The  barrel  is  made  of  either 
celluloid  or  glass,  and  the  piston  of  asbestos  or  well-oiled 
leather.  Its  capacity  is  12  c.c.  When  not  in  use  the 
syringe  should  be  kept  immersed  in  carbolic  lotion. 

Fig.  10  illustrates  the  so-called  '  Ockart '  sN'ringe, 
which  is  peculiar  in  that  the  piston-rod  is  in  the  form  of 
a  screw.  By  this  arrangement  any  sudden  jerking  of  the 
injection  is  prevented.     Though  an  excellent  syringe,  its 

4—2 


^2      Treatment  of  Gonorrhoea  in  the  Male 


cost  is  relatiNcl)-  high,  and  the  piston-rod  somewhat 
fragile.  I  therefore  prefer  the  simpler  form  shown  in 
Fig.  (). 

The  i>alicnt  must  be  directed  to  pass 
water  with  a  \iew  to  clearing  the  urethra 
of  its  pus  ;  then  to  inject  a  syringeful  of 
warm  water  and  to  allow  it  to  escape. 
This  is  to  be  repeated  a  time  or  two,  the 
object  being  to  remove  all  trace  of  urine 
from  the  urethra,  as  almost  all  the  in- 
jection fluids  are  readily  decomposed  by 
urine.  A  syringeful  of  the  solution  is 
then  injected.  As  the  capacity  of  the 
urethra  varies  somewhat  according  to 
the  severity  of  the  inflammation  of  its 
walls,  the  injection  should  be  stopped  if 
a  feeling  of  pain  is  caused  from  distension. 
The  fluid  should  be  retained  in  the 
urethra  by  compressing  the  meatus  with 
the  finger  and  thumb  for  a  length  of  time 
\arying  with  the  nature  of  the  fluid.  If 
it  is  of  a  bland,  unirritating  character, 
such  as  protargol  or  sulphate  of  thallin,  it 
should  be  retained  for  ten  minutes  or 
longer,  in  order  that  the  fullest  oppor- 
tunity may  be  given  for  the  fluid  to 
destroy  the  micrococcus.  When  the  fluid 
is  of  an  astringent  nature,  like  sulphate 
of  zinc,  a  shorter  time  is  adxisable. 
I  usually  start  the  treatment  by  ordering 
the  injection  of  I  per  cent,  protargol  or  argyrol  solution 
three  times  a  day,  the  fluid  to  be  retained  in  the  urethra 
four  minutes.  The  effect  of  this  treatment  is  generally 
very  marked,  the  purulent   discharge  rajiidly  tliminishes. 


Fig. 


Treatment  of  Acute  Anterior  Urethritis      53 

and  the  jiaiii  and  ])riripi.sm  disapj)car.  When  these  effects 
are  secured,  the  stren;:^'th,  duration,  and  frefjuency  of  the 
injections  may  be  gradually  increased,  At  the  end  of 
the  third  day  the  strength  of  the  fluid  may  be  raised  to 
^  per  cent,  solution,  at  the  end  of  the  week  to  f  per 
cent.,  and  on  the  tenth  day  to  i  per  cent.  At  the  same 
time  the  injections  are  given  more  frequently — four,  hve, 
or  six  times  a  day — and  the  fluid  retained  for  five  minutes. 
This  is  all  contingent  upon  the  injections  being  well 
borne,  causing  neither  smarting  nor  discomfort,  and  on 
the  inflammatory  symptoms  declining.  Sometimes  these 
protargol  injections  are  not  well  tolerated.  Instead  of 
being  painless,  they  give  rise  to  severe  smarting  and 
increase  of  the  inflammation.  Should  this  happen,  the 
protargol  solution  must  be  replaced  by  one  of  sulphate  of 
thallin  (i  to  i  per  cent.). 

Under  the  above  treatment  the  inflammatory  symptoms 
usually  rapidly  abate,  the  pain  on  micturition  and  priapism 
disappear,  and  the  secretion  diminishes  greatly  in  quantity, 
and  becomes  less  purulent  and  more  mucoid  in  character; 
the  pus  cells  are  less  numerous  and  epithelial  cells  appear. 
The  gonococci  are  no  longer  seen  in  large  numbers,  and 
soon  almost  entirely  disappear.  When  this  change  has 
taken  place — usually  in  the  second  week — the  injection 
fluid  should  be  changed  to  one  having  more  astringent 
properties.  Twice  a  day,  morning  and  midda}',  per- 
manganate of  potash  (i  in  10,000)  ma}-  be  used,  and  in 
the  evening  nitrate  of  silver  (i  in  10,000).  The  strength 
of  the  latter  may  be  cautiously  increased  from  time  to 
time,  for  the  urethra  quickl}-  becomes  tolerant  of  these 
antiseptics,  so  that  what  at  first  caused  smarting  and 
discomfort  in  a  da}^  or  two  is  hardly  felt.  For  the  same 
reason  it  is  well  occasionally  to  var}^  the  nature  of  the 
injection.     It  must  be  understood  that  the  strength  of  the 


54      Treatment  of  Gonorrhoea  in  the  Male 

solutions  mentioned  al)o\c  ii'jn-esents  hut  an  average 
useful  strength.  The  more  acute  the  inilanimation  the 
weaker  the  injection  must  be.  The  effect  of  the  astringent 
treatment  is  soon  noticed,  the  discharge  rapidly  diminishes, 
until  it  disappears,  and  perhaps  only  a  '  thread  '  or  two 
can  be  detected  in  the  urine,  to  indicate  the  ])resencc  of 
any  inflammatory  action. 

At  this  stage  the  patient,  being  free  from  pain,  and  not 
seeing  any  discharge,  will  almost  inevitably  believe  him- 
self to  be  cured  ;  and  unless  his  error  be  pointed  out  to 
him  by  his  medical  attendant,  will  withdraw  himself  from 


Fig.   io. 

all  further  treatment.  Should  he  do  so  and  return  to  his 
former  mode  of  living,  in  all  probability  the  discharge  will 
reappear  ;  for  the  gonococci,  not  being  completely  elimin- 
ated, will,  under  favourable  circumstances,  rekindle  the 
intlanimation.  In  the  normal  course  of  the  disease  a  cure 
is  rarely  obtained  under  five  or  si.\  weeks,  which  period 
will  be  prolonged  should  exacerbations  or  complications 
take  place. 

Should  the  disease  still  persist  at  the  end  of  the  sixth 
or  eighth  week,  as  evidenced  by  the  presence  of  mucus 
and  threads  in  the  urine,  it  must  be  regarded  as  having 
passed  into  the  subacute  or  chronic  stage,  and  will  require 
treatment  appropriate  to  that  condition,  the  details  of 
which  are  to  be  found  under  that  section  (see  p.  8g). 

We  may  now  ask,  by  what  si^j^us  can  we  determine  thai  the 
disease  is  cured  ?  The  answer  to  this  pertinent  question  is 
to  be  found  only  in  a  periodical  examination  of  the  urine.    As 


Treatment  of  Acute  Anterior  Urethritis 


.■)."» 


lon^  as  the  tirinc  first  passed  in.  t/ic  nuirnin<^  shows  '  urethral 
threads '  floating  in  it,  the  urethra  is  still  inflamed. 

Are  we,  then,  to  continue  the  injections  until  ;ill  the 
'  threads  '  have  disappeared  ? 

Although  some  authorities  would  ;insw(;r  this  question 
in  the  affirmative,  it  is  not,  to  my  mind,  a  sound  con- 
clusion. For  it  sometimes  happens  that  long  after  the 
gonorrhoeal  inflammation  has  subsided  *  threads '  are 
passed  consisting  only  of  epithelial  cells  held  together  by 
mucin,  this  desquamative  catarrhal  condition  being  kept 
up  by  the  astringent  injections.  Therefore,  towards  the 
end  of  the  treatment  it  is  well  from  time  to  time  to  make 
a  short  break  in  the  local  applications,  in  order  to  ascer- 
tain how  far  the  secretion  is  due  to  the  action  of  the 
astringents. 

So  long  as  the  'threads'  shoiv  the  presence  of  gonococci,  even 
occasionally,  the  disease  is  not  cured.  The  patient  is  infections, 
and  the  treatment  must  be  continued.  Even  if  pus  cells  are 
constantly  to  he  seen  in  the  'threads,''  it  is  most  probable  that 
the  gonococcus  still  lurks  somewhere  in  the  urethra. 

On  the  other  hand,  should  repeated  examinations  of  the 
'  threads '  show  that  they  consist  principally  of  epithelial 
cells,  and  no  gonococci  are  present,  all  treatment  may 
cease. 

But  the  patient  must  be  kept  under  observation  for  a 
fortnight  longer,  or  more,  for  it  is  possible  that,  after  all 
injections  have  been  stopped,  and  the  patient  has  returned 
to  a  more  stimulating  diet  and  manner  of  life,  the  discharge 
will  reappear,  the  gonococci  which  have  lurked  in  some  crypt 
or  follicle  rekindling  the  inflammation.  The  procedure  to 
be  adopted  in  order  to  determine  whether  the  disease  is 
definitely  cured  or  not  is  described  in  Chapter  VII.,  where 
the  subject  is  considered  at  greater  length. 


CHAPTER  IX 

THE  TREATMENT  OF  ACUTE  POSTERIOR   URETHRITIS 

As  the  extension  of  the  inflammation  to  the  posterior  part 
of  the  urethra  does  not  usually  take  place  until  about  the 
third  week  after  the  beginning  of  the  attack,  it  usually 
happens  that  the  case  is  under  treatment  when  this  com- 
plication sets  in.  If  the  extension  of  the  inflammation 
gives  rise  to  ver}-  acute  symptoms — haematuria,  frequent 
micturition,  or  seminal  emissions — all  injections  should  be 
stopped  until  these  symptoms  have  died  down.  As  in 
anterior  urethritis  at  such  a  period,  the  treatment  must  be 
purely  constitutional,  all  local  interference  tending  to 
aggravate  the  inflammation. 

(1)  Constitutional  Treatment. 

The  constitutional  treatment  is  the  same  as  that  for 
anterior  urethritis,  with  the  exception  that  salicylate  of 
soda  is  generally  more  useful  than  the  balsams.  This 
drug,  though  of  comparatively  little  value  in  inflammation 
of  the  anterior  urethra,  has  a  very  beneficial  action  in 
posterior  urethritis.  Under  its  action  the  urine  rapidly 
clears,  and  the  acute  distressing  symptoms  disappear.  It 
may  be  given  in  doses  of  lo  to  30  grains  three  times  a 
day.  Salol  or  salicine  may  be  used  instead,  but  I  prefer 
the  salicylate  of  soda.     These  drugs  have  the  great  advan- 

56 


Treatment  of  Acute  Posterior  Urethritis     57 

ta.^'c  of  rendering  the  mine  niiirkedly  ,'i(  id,  n.  point  of  f;on- 
siderable  importance;  for,  by  maintaining  the  acidity  of 
the  urine,  we  use  our  strongest  prophylactic  against  the 
urethral  inllammation  extending  to  the  bladder,  and  so 
producing  cystitis.  Although,  as  I  have  said,  salicylate  of 
soda  is  generally  more  efficacious  in  those  cases  than  any 
of  the  balsams,  it  is  not  always  so.  If  it  fails  speedily  to 
reduce  the  symptoms,  one  of  the  balsams  should  be  given. 

The  desirability  of  maintaining  the  acidity  of  the  urine 
must  also  be  borne  in  mind  when  dieting  the  patient.  A 
light  milk  diet,  with  the  substitution  of  mineral  waters  for 
alcoholic  drinks,  as  so  often  recommended,  causes  a  decided 
and  undesirable  reduction  in  the  acidity  of  the  urine.  A 
further  factor  in  reducing  the  acidity  is  the  regurgitation 
of  the  alkaline  pus  into  the  bladder  during  the  night.  The 
powerful  predisposing  influence  that  alkaline  urine  exercises 
in  the  production  of  cystitis  is  well  known.  It  is  well, 
therefore,  not  to  restrict  the  patient  exclusively  to  a  milk 
diet,  but  to  allow  a  fair  amount  of  red  meat,  and  mineral 
waters  should  be  avoided.  Apart  from  the  administration 
of  salicylate  of  soda,  the  treatment  must  also  be  directed 
to  combating  the  three  prominent  symptoms  of  acute 
posterior  urethritis — vesical  tenesmus,  haemorrhage,  and 
seminal  emissions.  The  first  may  be  mitigated  by  seda- 
tives, such  as  belladonna  and  hyoscyamus  and  the  use  of 
hot  sitz-baths.  Should  the  distress  be  ver}-  great,  small 
doses  of  morphia  may  be  given,  but  this  drug  must  be 
administered  cautiously,  large  doses  tending  to  increase 
the  vesical  irritability. 

As  a  rule,  the  slight  haemorrhage  which  accompanies 
the  vesical  tenesmus  is  best  treated  by  the  sedatives  above 
mentioned.  When  of  a  severe  character  and  unaccom- 
panied by  vesical  tenesmus,  it  ma}'  be  restrained  by  the 
administration  of  ergotin  or  perchloride  of  iron,  or,  better? 


5^^       Treatment  of  Gonorrhoea  in  the  Male 

by  the  instillation  of  cocaine  (2  per  cent.)  and  adiLiKilin 
(i  in  1,000). 

The  tendenc}'  to  frecjnent  seminal  emissions,  which  is  so 
common  a  feature  of  this  disease,  must  be  energetically 
combated,  for  the  intmsL'  hyi)Lr;Lmi:i  tiny  cause  is  in  the 
highest  degree  injurious,  retarding  ihc  recovery  of  the 
mucous  membrane. 

The  importance  of  rest  in  thr  treatment  of  acute 
gonorrhoea  has  already  been  noticed,  but  it  must  be  em- 
phasized in  connection  with  acute  posterior  urethritis. 
During  the  acme  of  the  disease  the  patient  should  be  kept 
in  bed ;  indeed,  his  condition  is  often  so  pitiful  that  he  has 
little  desire  to  be  about. 

(2)    Local  Treatment. 

The  principles  of  treatment  for  acute  posterior  urethritis 
are  the  same  as  have  been  laid  down  for  the  acute  anterior 
urethritis,  namely,  to  withhold  local  applications  during 
the  acutest  stage  of  the  disease.  When  this  stage  is  passed, 
and  as  the  inflammation  subsides,  the  bland  antiseptics 
may  be  used,  and  gradually  changed  to  more  astringent 
ones.  The  application  of  these  remedies  requires  certain 
modifications  of  the  method  advocated  in  the  preceding 
section.  When  the  tenesmus  and  other  painful  symptoms 
have  quite  disappeared  under  the  constitutional  treatment, 
the  local  applications  may  be  begun  by  ordering  the 
patient  a  dilute  solution  of  protargol  (]  to  \  per  cent.)  or 
sulphate  of  thallin  (i  per  cent.).  The  solution  may  be 
injected  three  or  four  times  a  day  in  the  manner  described 
when  speaking  of  acute  anterior  urethritis.  As  these 
fluids  are  non-irritating,  they  do  not  usually  produce  a 
powerful  contraction  of  the  compressor  urcthrce  muscle, 
and  so  are  allowed  to  pass  into  the  posterior  urethra.  The 
injection   should   be    retained   in    the    urethra    for    fifteen 


Treatment  of  Acute  Posterior  Urethritis     59 

minutes,  so  that  tin;  |)iimciry  contraction  of  tin:  com- 
pressor urethra;  may  relax  and  allow  tlic  llnid  If)  pass 
backwards.  The  patient  should  be  instructed  to  aid  the 
passage  of  the  fluid  by  relaxing  as  far  as  possible  the  com- 
pressor muscle — that  is  to  say,  he  should  try  to  micturate 
while  the  injection  is  being  made.  The  beneficial  effect 
of  the  injections  is  generally  (juickly  seen.  Within  a  few 
days  the  purulent  secretion  diminishes  and  becomes  more 
mucoid  in  character.  When  this  takes  place  and  all 
painful  symptoms  are  absent,  the  astringent  remedies  may 
be  applied.  But  it  is  useless  to  order  them  to  be  injected 
with  the  ordinary  gonorrhoeal  syringe ;  the  fluid  would 
never  pass  the  compressor  urethrse,  the  irritating  solution 
setting  up  so  powerful  a  spasm  of  that  muscle.  As  we 
have  seen,  it  is  difficult  enough  to  inject  a  bland  unirritat- 
ing  fluid  into  the  posterior  urethra,  but  it  would  be  im- 
possible to  inject  the  astringent  and  irritating  fluid  we 
now  wish  to  use.  We  must,  therefore,  adopt  other 
measures.  There  are  two  methods  by  which  our  end 
may  be  attained.  One  is  by  gradually  increasing  the 
pressure  of  the  fluid  injected  at  the  meatus  until  it  is 
sufficient  to  overcome  the  spasm  of  the  compressor 
urethrse  (Janet's  irrigation).  The  other  method  is  to 
inject  the  fluid  by  some  suitable  instrument,  such  as  a 
catheter  (Diday's  injection). 

Janet's  Irrig'ation. — This  method  was  originally  intro- 
duced as  an  abortive  treatment  of  acute  gonorrhoea,  and 
has  still  many  adherents,  but,  as  I  have  already  stated,  it 
is  for  this  purpose  both  uncertain  and  unsatisfactory.  It 
is  carried  out  by  means  of  an  irrigator  holding  a  pint  or 
more  of  fluid,  fitted  with  a  couple  of  yards  of  tubing  and  a 
conical  glass  cannula.  Fig.  11  depicts  Valentine's  instru- 
ment for  the  purpose.  According  to  Janet,  the  temperature 
of  the  irrigation  fluid  should  in  all  cases  be  from  38°  to 


6o       Treatment  of  Gonorrhoea  in  the  Male 

40°  C.  The  patient  havinj;  first  half  emptied  the  bladder, 
so  -as  to  clear  the  urethra  of  pus,  the  end  of  the  glass 
cannula  is  inserted  into  the  meatus  and  the  irrif::ator  raised 


Fig,  II. — Valentine's  Urethkal  Ikrigatok. 

a  foot  or  two.  The  pressure  of  the  fluid  is  sufficient  to 
distend  the  anterior  urethra,  hut  not  to  overcome  the 
compressor   muscle.     Tlie  cannula  is  then  removed,  and 


Treatment  of  Acute  Posterior  Urethritis     ^>i 

the  iiuid  allowed  to  cscaj)C  from  the  iinjllira.  After  this 
has  been  repeated  two  or  three  times  with  a  view  to 
thoroughly  washing  out  the  anterior  urethra,  the  rnnnuln 
is  reinserted,  and  the  irrigator  slowly  raised  until  tin; 
pressure  of  the  lluid  is  sufhcient  to  overcome  the  com- 
pressor muscle,  and  the  lotion  enters  the  posterior  urethra 
and  passes  on  to  the  bladder.  As  a  rule,  the  irrigator 
must  be  raised  from  i^  to  2  yards  before  the  resistance  of 
the  compressor  muscle  is  overcome.  The  irrigation  is 
best  done  with  the  patient  lying  on  his  back  with  the  legs 
apart.  As  the  irrigator  is  being  raised,  the  patient  should 
be  instructed  to  relax  the  urethral  muscles  by  trying  to 
micturate.  It  is  by  no  means  always  easy  to  inject  into 
the  posterior  urethra  by  this  means,  the  distension  of  the 
urethra  sometimes  causing  severe  pain.  Where  this  is  the 
case,  it  is  well  to  give  a  small  preliminary  injection  of  a 
weak  cocaine  solution  (i  per  cent.)  a  few  minutes  before 
irrigating.  The  principal  advantages  of  this  method  are 
that  the  pressure  of  the  fluid,  by  stretching  the  urethral 
mucous  membrane  and  obliterating  its  folds,  insures  the 
lotion  coming  into  contact  with  its  entire  surface.  It  is 
often  easier  and  more  convenient  to  administer  this  in- 
jection by  means  of  a  large  wound  syringe  fitted  with  a 
conical  nozzle,  especially  when  it  is  desired  to  use  only  a 
relatively  small  quantity  of  fluid. 

Diday's  Irrig-ation. — The  patient  having  half  emptied 
the  bladder  as  before,  a  large,  soft  rubber  catheter  is 
passed  till  its  eye  lies  just  outside  the  bladder.  The 
lotion  is  then  injected  by  means  of  either  a  large  s\-ringe 
or  an  irrigator  as  the  catheter  is  slowly  withdrawn.  As 
long  as  the  eye  of  the  catheter  lies  behind  the  membranous 
urethra,  the  fluid  will  pass  backwards  into  the  bladder ; 
when  the  eye  has  left  the  membranous  part,  the  fluid  \\ill 
escape   at   the    meatus.     In    this  way  the  whole   of  the 


62       Treatment  of  Gonorrhoea  in  the  Male 

m\'tlira  is  th()rou{;hl}'  irri,!^ated.  The  l)laddcr  is  oiil}-  hall 
emptied,  in  order  that  the  lotion  on  entering  it  may  be 
decomposed  by  the  urine,  and  so  rendered  inert,  thus 
effectually  preventing^  the  solution  from  unnecessarily 
irritatuii,'  tlie  vesical  nitu-ous  iiienihrane.  Abundant 
experience  has  shown  that  the  fear  of  infecting  the  bladder 
by  these  methods  of  irrigation  is  groundless.  The  fluid 
injected  into  the  bladder  does  not  require  to  be  removed 
by  the  surgeon  ;  it  is  passed  naturalh-  at  the  close  of  the 
procedure. 

Of  the  two  irrigation  methods,  that  of  Diday"s  is  to  be 
generally  preferred,  as  being  easier  of  performance  and 
causing  less  pain  and  irritation  to  the  parts  concerned.  It 
is  better  to  reserve  Janet's  method  for  the  more  chronic 
forms  of  the  inflammation. 

When  starting  the  irrigation  it  is  best  to  select  very 
weak  solutions  of  mild  remedies,  such  as  protargol  (j-  to  i 
per  cent.)  or  sulphate  of  thallin  (i  per  cent.),  and  after  a 
few  days  to  pass  on  to  stronger  and  more  astringent 
solutions,  such  as  permanganate  of  potash  (i  in  2,000 
to  10,000)  or  nitrate  of  silver  (i  in  10,000  to  i  in  500). 
As  a  rule  the  nitrate  of  silver  solutions  are  the  most 
efficacious. 

Tile  irrigation  is  performed  by  the  surgeon  every  two  or 
three  days,  the  patient  continuing  his  injections  with  the 
small  syringe  twice  a  day.  In  a  week  or  two  the  secretion 
diminishes,  so  that  it  only  manifests  itself  as  a  slight 
mucous  cloud  and  by  the  presence  of  a  few  '  urethral 
threads  '  in  both  portions  of  the  urine. 

We  may  now  proceed  to  use  remedies  of  greater 
strength,  applying  them  in  minute  quantities  by  the 
method  of  instillation. 

Instillation. — There  are  two  instruments  used  for  this 
purpose  :     one    is   Guyon's    instillation   syringe,    and    the 


Treatment  of  Acute  Posterior  Urethritis    63 

other  is  Ult;<mann's.  Guyon's  instrument  (l'"i^'.  12)  is 
furnished  with  a  tine  flexible  '  ueorn-headed  '  eatheter ; 
Ultzmann's  (Fig.  13)  has  a  rigid  metal  or  vulcanite 
catheter,  also  with  a  fine  terminal  opening.  Both  instru- 
ments are  well  adapted  for  tlicir  i)urpose,  but  I  prefer  that 


Fig,  12. 


Fig.  13. 


of  Ultzmann's,  as  it  is  more  readily  introduced  and  more 
easily  sterilized.  The  catheter  is  lubricated  with  glycerine  ; 
oil  must  never  be  used,  as  it  would  smear  the  epithelium 
and  protect  it  from  the  injection.  The  catheter  is  intro- 
duced as  far  as  the  vesical  orifice,  then  slowly  withdrawn, 
and  the  injection  fluid  applied  drop  by  drop  along  the 


64       Treatment  of  Gonorrhoea  in  the  Male 

wlu)le  of  tlie  urethra.  The  thiid  used  is  u  sohition  of 
nitrate  of  silver,  in  strength  \arying  from  \  to  ^  per  cent. 

The  instilhition  is  made  two  or  three  timos  a  week,  the 
patient  in  the  intervals  continuing  his  urethral  injections. 

Simple  posterior  urethritis,  unless  complicated  by  an 
infection  of  the  prostate,  generally  responds  readily  to 
treatment,  and  usually  clears  up  before  the  inflammation 
in  the  anterior  part.  When,  therefore,  it  is  seen  that  the 
second  portion  of  the  morning  urine  is  constantly  clear, 
the  special  treatment  of  the  posterior  urethra  should  be 
stopped,  and  the  anterior  urethra  only  treated. 

In  those  cases  where  the  posterior  urethritis  persists  in 
spite  of  treatment  for  more  tlian  Ine  or  six  weeks,  it  is 
generally  due  to  an  infection  of  the  prostate  or  vesicuhe. 

Note. — It  may  be  well  to  give  in  some  detail  Janet's  per- 
manganate of  potassium  treatment  for  urethritis,  as  it  has 
been  so  largely  adopted,  although  I  personally  regard  it 
as  decidedly  inferior,  for  the  majority  of  the  cases,  to  the 
treatment  which  I  have  already  described.  Since  the 
original  publication  Janet  has  repeatedly  modified  the 
details  of  his  method  of  procedure,  and  the  following 
account  has  just  been  issued  b}'  Kollmann*  as  the  one 
recently  sketched  out  to  him  by  Janet  himself. 

During  the  first  three  or  four  days  of  an  acute  urethritis 
of  the  anterior  portion  the  irrigation  is  given  twice  daily. 

Gradually  longer  intervals  are  interposed,  so  that  the 
irrigations  take  place  only  every  eighteen,  twenty-four, 
thirty-six,  or  forty-eight  hours.  As  the  diffuse  turbidity 
of  the  urine  disappears  the  interval  is  increased  from 
eighteen  to  twenty-four  hours,  and  from  thirty-six  to 
forty-eight  hours  when  the  secretion  is  no  longer  purulent. 
Should  an  infection  of  the  posterior  part  take  place  during 

*  Oberlanclcr  ai  d  Kollmann,  '  Die  chronische  (".onorrhiu  dcr  mann- 
lichen  Harniohre.'     1905. 


Treatment  of  Acute  Posterior  Urethritis    65 

the  treatment,  the  vvhoh;  iircthr.i  niiist  iiiiiii(f]i;it<:ly  he 
irrif^ated  twice  daily,  just  as  in  the  commencement  of  the 
treatment,  when  the  anterior  part  alone  was  affected. 
After  a  few  days  the  urine  will  generally  clear  again. 
From  this  time  the  posterior  irrigation  may  be  dropped, 
and  the  anterior  one  alone  continued.  In  an  acute  anterior 
urethritis,  without  excessive  inflammatory  symptoms, 
^j  litre  of  a  I  in  500  solution  of  permanganate  of 
potassium  is  used,  immediately  followed  by  an  irrigation 
of  -2"  litre  of  boracic  lotion.  This  strength  is  maintained 
throughout  the  entire  course  of  treatment,  always  provided 
that  no  signs  of  intolerance  appear.  When,  towards  the 
end  of  the  treatment,  it  is  thought  that  the  disease  is 
cured,  pauses  of  thirty-six  to  forty-eight  hours  are  made 
and  a  solution  of  from  i  in  3,000  to  i  in  4,000  is  used 
without  the  subsequent  boracic  irrigation.  Should  an 
infection  of  the  posterior  portion  arise  during  the  treat- 
ment, or  be  present  previously,  then  only  weak  solutions 
of  a  strength  of  i  in  10,000  to  i  in  4,000  must  be  resorted 
to  if  the  passage  of  it  into  the  bladder  be  difficult.  If, 
however,  the  solution  passes  in  easily,  then  a  strength  of 
I  in  2,000  to  I  in  1,000  may  be  used,  following  it  up  with 
the  boracic  irrigation.  In  cases  where  the  acute  inflam- 
matory symptoms  are  considerable,  very  weak  solutions 
of  I  in  10,000  to  I  in  4,000  should  be  used,  and  only  the 
anterior  portion  irrigated,  even  if  the  posterior  be  also 
affected.  The  whole  urethra  should  not  be  irrigated  until 
the  acute  inflammatory  symptoms  have  subsided.  When 
the  acute  stage  is  over  it  is  sufficient  to  irrigate  with  a 
medium  strength  of  i  in  2,000  to  i  in  1,500  once  daily. 
The  temperature  of  the  solution  must  always  be  from  38° 
to  40°  C.  Care  must  be  taken  to  see  that  the  bladder  is 
emptied  immediately  after  the  irrigation,  otherwise  the 
permanganate  of  potassium  solution  will  cause  irritation. 

5 


CHAPTER  X 

CHRONIC    URETHRITIS 

The  symptoms  of  acute  i^onorrhcea  usuall}-  begin  to  abate 
about  the  end  of  the  third  week,  and  gradually  die  down, 
until,  towards  the  close  of  the  fifth  or  sixth  week,  the 
entire  process  is  complete.  This  rapid  recovery,  how- 
ever, is  liable  to  be  indefinitely  prolonged  by  a  variety  of 
causes,  as  relapse,  or  by  the  extension  of  the  inflammation 
to  the  posterior  urethra.  In  such  cases  the  disease  is  apt 
to  become  chronic,  the  diffuse  inflammation  of  the  acute 
stage  becoming  localized  in  one  or  more  small  circum- 
scribed areas. 

Attention  has  already  been  drawn  to  the  fact  that  as 
soon  as  the  painful  symptoms  have  passed  away  and  the 
free  discharge  has  ceased,  the  patient  is  very  likely  to 
tliink  himself  cured,  and  therefore  withdraws  himself  from 
further  treatment,  or,  at  any  rate,  relaxes  all  stringent 
regulations  as  to  diet,  rest,  etc.  The  usual  effect  of  this 
indiscretion  is  to  provoke  afresh  the  symptoms  of  the 
acuter  stage  of  the  disease.  Such  a  relapse  may  occur 
again  and  again,  and  each  time,  though  the  inflammatory 
reaction  is  less  acute  than  before,  it  runs  a  much  more 
tedious  course. 

At  times  the  rekindling  of  the  inflammation  is  due  to  a 
fresh  infection,  for  gonorrhcea  gives  no  immunity  from  a 
recurrence  of  the  disorder ;  a  reinoculation  may  therefore 

66 


Chronic  Urethritis  67 

take  place  at  any  period.  I>iit  in  the  lar|:,'e  majority  of 
cases  the  recrudescence  is  a  relapse,  and  not  the  result  of 
a  reinfection.  This  is  proved  by  the  fact  that  the  acute 
symptoms  follow  directly  upon  the  sexual  indiscretion, 
and  not  after  an  incubative  period  r)f  some  three  rjr  four 
days,  as  they  would  if  they  were  due  to  a  reinfection. 

Another  frequent  cause  of  the  inflammatory  condition 
becoming  chronic  is  its  extension  to  the  posterior 
urethra.  Although,  as  we  have  seen,  this  usually  yields 
quickly  to  appropriate  treatment,  it  is  specially  prone 
to  severe  exacerbation  when  treated  in  an  unsuitable 
manner. 

It  is  becoming-  increasingly  evident  that  in  the  great 
majority  of  cases  of  chronic  urethritis  the  prostate  has 
become  affected,  the  inflammation  spreading  to  and 
infecting  its  numerous  mucous  glands,  from  which  it 
can  be  dislodged  only  with  the  utmost  difficulty.  It  is 
necessary  to  emphasize  the  frequency  with  which  the 
glands  of  the  prostate  are  affected  in  chronic  gonorrhoea. 
There  is  unfortunately  a  widely-spread  opinion  that  this 
gland  is  but  rarely  affected  with  gonorrhoea,  and  that 
when  it  is  so  affected  the  symptoms  provoked  are  so 
striking  and  urgent  as  to  prevent  the  complication  being 
overlooked.  This  is  true  only  of  that  rare  form  of  pros- 
tatitis which  runs  an  acute  course,  and  terminates  in 
prostatic  abscess. 

But  there  is  another  and  far  more  common  form,  which 
develops  insidiously  and  gives  rise  to  a  muco-purulent 
desquamative  catarrh  of  the  numerous  glands  of  the 
prostate.  I  have  recently  paid  considerable  attention  to 
this  point,  and  I  hope  ere  long  to  publish  some  statistics 
on  it.  Without  going  into  details  now,  I  may  briefl}-  say 
that  the  frequency  with  which  the  prostate  is  involved  is 
greatly  underestimated.      My  own  observation  leads  me 

5—2 


68       Treatment  of  Gonorrhoea  in  the  Male 

to  conclude  that  the  infection  is  present  in  the  majorit\' 
of-  cases  where  the  disease  has  become  chronic.  There 
are  certain  constitutional  conditions,  such  as  phthisis, 
anamia,  and  general  ill-health,  w  hich  seem  to  play  some 
part,  though  a  distinctly  minor  one,  in  rendering  the 
attack  chronic. 

There  is  naturally  no  sharj)  line  to  l)e  drawn  between 
the  morbid  processes  observable  in  the  acute  and  the 
chronic  forms  of  this  disease,  the  one  form  merging 
imperceptibly  into  the  other.  The  general  diffuse  inflam- 
mation of  the  acute  stage  dies  down  save  in  certain  places 
more  or  less  circumscribed,  where  it  lingers.  Here,  in 
consequence  of  the  prolonged  irritation  of  the  gonococci, 
there  is  called  forth  a  proliferation  of  the  subepithelial 
tissue  cells,  forming  the  so-called  small-celled  infiltration. 
This  proliferation  of  the  connective  tissue  cells  may  be 
regarded  as  marking  the  onset  of  the  chronic  stage. 
These  areas  of  small-celled  infiltration  are  generally 
themselves  small  and  circumscribed,  and  most  frequentl}- 
are  situated  round  or  about  the  lacunae  and  ducts  of  the 
mucous  glands.  As  the  infiltrations  are  accompanied  by 
a  considerable  increase  in  vascularity,  they  present  a 
granular  appearance. 

These  circumscribed  infiltrations  develop  immediately 
beneath  the  epithelium,  which  at  first  lies  over  them, 
either  unchanged  or  but  slightly  cedematous  and  loosened. 
Erosions  or  ulcerations  are  decidedly  rare.  After  a  time 
the  infiltration  undergoes  a  form  of  sclerosis,  spindle- 
shaped  connective  tissue  cells  and  fibres  developing,  and 
the  soft  infiltration  gradually  passing  into  a  fibroid  scar. 
At  the  same  time  the  epithelium  lying  over  it  also  under- 
goes a  metaplasia,  gradually  losing  its  cylindrical  form 
and  assuming  a  stratified,  squamous  type.  Similar 
changes  may  be  observed  in  other  parts  of  the  body — as, 


Chronic  Urethritis  69 

for  cxninple,  the  growtli  of  tlu;  (;{)itheliuiii  over  scar  tissue 
in  the  intestine. 

The  pHncipal  inflammatory  changes  occur  in  the  rcf^ion 
of  the  mucous  foHicles  and  ducts  of  the  glands  of  Littrc 
and  Morgagni.  Consequently  it  is  in  those  portions  of 
the  urethra  which  are  richest  in  glandular  tissue  (such  as 
the  prostatic  and  bulbous)  that  the  inflammation  is  most 
marked  and  lingers  the  longest.  The  rich  glandular  tissue 
of  the  prostate,  especially  in  the  neighbourhood  of  the 
caput  gallinaginis,  is  very  prone  to  chronic  inflammation, 
giving  rise  to  a  desquamative  or  purulent  catarrh  of  the 
glands.  The  subsequent  cicatricial  contraction  causes  a 
narrowing,  or  obliteration,  of  the  ducts,  and  the  forma- 
tion of  small  mucous  cysts  and  abscesses. 

As  a  rule  the  inflammation  does  not  extend  beyond 
the  subepithelial  tissue,  the  deeper  structures  being  un- 
affected. When,  however,  the  periurethral  tissues  do 
become  involved,  the  subsequent  cicatricial  contraction 
causes  a  diminution  in  the  calibre  of  the  urethra,  and  so 
gives  rise  to  the  formation  of  a  stricture. 


Classification. 

The  forms  of  chronic  urethritis  are  convenientl)' 
divided,  both  pathologically  and  clinicall}-,  into  two 
classes,  determined  by  the  inflammation  being  either 
limited  to  the  mucous  membrane,  as  it  usually  is,  or 
extended  to  the  deeper  subepithelial  tissues.  The  classes 
are  thus  denominated  by  Finger  : 

I.  Urethritis  Chronica  Anterior. 
This  embraces  two  subdivisions  : 

(r)   Urethritis  chronica  anterior  superficialis  mucosa. 

(2)   Urethritis  chronica  anterior  profunda. 


;o      Treatment  of  Gonorrhoea  in  the  Male 

II.    rivthntis  Chronica  Posterior. 
This  also  embraces  two  sections  : 

(i)  Urethritis  chronica  posterior  superliciahs  mucosa. 

(z)  Urethritis  chronica  posterior  profunda. 

Symptoms  of  Chronic  Urethritis.  —  The  symptoms 
of  chronic  urethritis  \ary  according  to  the  degree  of 
the  inllainmation  present  and  thi;  extent  and  depth  of 
the  urethra  involved.  In  the  earlier  stages,  when  the 
acute  inilammation  is  beginning  to  settle  down  into 
the  chronic  condition,  and  when  there  is  still  a  large 
extent  of  mucous  surface  affected,  the  discharge  is  the 
most  prominent  symptom.  This  discharge  is  usually 
profuse,  although  the  amount  and  character  of  it  may 
vary  considerably. 

As  the  inflammation  becomes  localized  to  one  or  more 
spots  in  the  urethra,  the  discharge  lessens  in  amount,  and 
passes  from  the  purulent  condition  to  a  thin,  clear  mucus, 
just  sufficient  to  stick  the  lips  of  the  meatus  together. 
The  urine  is  more  or  less  cloudy,  according  to  the 
quantity  of  secretion  present,  and  seldom  fails  to  show 
the  presence  of  urethral  or  gonorrhoeal  *  threads.' 
Numerous  attempts  have  been  made  to  diagnose  the  seat 
of  the  chronic  inflammation  by  the  form  and  appearance 
of  these  threads,  but  so  far  without  marked  success. 
Two  distinct  forms  are,  however,  met  with — one  a  long, 
slender,  transparent,  gelatinous  thread,  the  formation  of 
which  has  been  already  described  ;  the  other  a  short, 
stout,  yellowish,  opaque  body,  which  is  derived  from  the 
various  gland  ducts  and  follicles  of  the  urethra.  The 
presence  of  these  latter  bodies  in  large  numbers  is  a  sure 
sign  of  an  intense  inflammation  of  the  urethral  glands, 
and  therefore  a  call  for  unfavourable  prognosis. 


Chronic  Urethritis  71 

Chronic  Urethritis  Anterior. 

Symptoms. — When  tlic  iiillammation  is  loc;ili;ced  in  the 
anterior  urethra,  and  is  Hmited  to  the  mucous  membrane 
— that  is  to  say,  has  not  affected  the  submucous  tissue — 
it  causes  but  Httle  inconvenience  to  the  patient.  There  is 
usually  a  complete  absence  of  pain  on  micturition,  though 
sometimes  a  slight  irritation  is  felt  at  the  end  of  the  penis. 
The  most  noticeable  symptom  is  the  well-known  bead 
of  purulent  secretion,  which  is  found  at  the  meatus  on 
waking  in  the  morning,  and  is  aptly  called  the  '  bon-jour 
drop.'  The  secretion  is  so  slight  that  during  the  day, 
when  the  urethra  is  frequently  irrigated  by  the  stream  of 
urine,  the  drop  of  pus  may  not  be  seen,  though  the  lips 
of  the  meatus  may  stick  together. 

If  the  urine  be  divided  into  two  portions — Sir  Henry 
Thompson's  test — the  first  only  will  be  cloudy,  the  second 
portion  clear.  If  the  urethritis  be  fairly  recent,  the  first 
portion  of  urine  will  be  turbid  from  mucus,  and  will  show 
the  presence  of  urethral  threads.  If  the  process  be  of 
long  standing  and  free  from  any  exacerbation,  the  urine 
will  be  quite  clear  and  free  from  mucus,  but  will  show 
the  threads  floating  in  it.  Often  the  only  sigji  of  a  chronic 
urethritis  is  the  presence  of  a  few  urethral  threads  floating  in 
the  urine  first  passed  in  the  morning,  the  secretion  in  such 
cases  being  too  slight  and  tenacious  to  appear  at  the 
meatus  as  the  *  bon-jour  drop.'  Should  the  inflammation 
extend  to  the  tissues  beneath  the  mucous  membrane, 
other  and  more  serious  symptoms  are  likely  to  develop. 
For,  as  the  succulent  small-celled  infiltration  gradually 
undergoes  cicatricial  contraction,  the  lumen  of  the  urethra 
is  diminished,  and  the  symptoms  of  a  stricture  are  added 
to  those  described  above. 


7-       Treatment  of  Gonorrhoea  in  the  Male 

Chronic  Urethritis  Posterior. 

Here,  as  in  chronic  anterior  uretliritis,  the  disease  is 
often  unnoticed  1)\-  the  jxitient,  owinj^  to  the  absence  of 
pain  or  appreciable  secretion.  And  it  is  only  the  presence 
of  the  urinary  threads  in  the  second  as  well  as  in  the  first 
portion  of  the  urine  passed  that  indicates  to  the  surgeon 
the  existence  of  the  disease.  As  long  as  the  inflammation 
is  superficial — that  is,  has  not  penetrated  deeper  than  the 
urethral  mucous  membrane  —  the  presence  of  slight 
turbidity  in  the  second  portion  of  the  urine  may  be  the 
only  symptom.  As  in  chronic  anterior  urethritis,  if  the 
inflammation  be  fairly  recent,  the  urine  will  be  cloudy 
from  the  presence  of  mucus,  and  floating  in  it  will  be 
seen  numerous  urethral  threads.  On  the  other  hand, 
when  the  inflammation  is  of  long  standing,  the  urine  will 
be  quite  free  from  mucus,  the  threads  floating  in  clear 
urine.  It  is,  however,  to  be  noticed  that  a  slight  exacerba- 
tion of  an  old  chronic  case  will  at  once  bring  back  the 
mucus  in  the  urine.  Such  exacerbations  are  most 
common. 

It  is  sometimes  possible  to  diagnose  the  presence  of 
posterior  urethritis  by  the  peculiar  appearance  of  the 
urinary  threads  alone.  The  prostatic  urethra  is  rich  in 
large  glands,  which  open  on  either  side  of  the  caput 
gallinaginis,  and  an  inflammation  of  this  part  is  sure  to 
affect  these  glands,  and  in  consequence  their  ducts  become 
blocked  with  thick  muco- purulent  matter,  which  is 
squeezed  out  in  the  form  of  small  comma-shaped  masses 
by  the  powerful  contraction  of  the  compressor  urethrae  at 
the  close  of  the  micturition.  The  presence  of  these  small 
comma-shaped  threads  of  muco-purulent  matter  should 
therefore  lead  one  to  suspect  an  inflammation  of  the 
prostatic  urethra.     Chronic  posterior  urethritis,  as  already 


Chronic  Urethritis  73 

stated,  is  frequently  iinattc'ndcd  by  siil;joctive  symptoms, 
as  long  as  the  inflammation  is  limited  to  the  mucous 
membrane  ;  but  should  the  deeper  structures  of  the 
urethra  become  involved,  most  distressing  symptoms  will 
be  evoked. 

The  urinary,  sexual,  and  general  nervous  symptoms  are 
due  to  the  inflammation  and  consequent  irritation  of  that 
highly-nervous  organ,  the  prostate.  One  of  the  earliest 
of  the  symptoms  is  a  distressing  desire  for  frequent 
micturition,  often  attended  by  considerable  pain  radiating 
from  the  neck  of  the  bladder  to  the  rectum,  hypogastrium, 
and  end  of  penis.  The  desire  to  empty  the  bladder  is  im- 
perative, and  the  patient  is  compelled  then  and  there, 
however  situated,  to  void  his  urine. 

Frequent  seminal  emissions  are  another  sign  of  irrita- 
tion in  the  prostatic  urethra,  and  at  times  develop  into 
a  true  spermatorrhoea.  But  more  commonly  what  the 
patient  looks  upon  as  the  involuntary  emission  of  seminal 
fluid  is  really  an  escape  of  prostatic  secretion — a  prosta- 
torrhoea — as  can  be  proved  by  a  microscopic  examination 
of  the  fluid.  The  prostatic  secretion  is  evidenced  by  the 
absence  of  spermatozoa  and  the  presence  of  sperm  crystals. 
The  frequent  seminal  emissions  have  a  most  disastrous 
influence  on  the  health  and  physique  of  the  patient,  and 
especially  if  accompanied  by  the  presence  of  spermatorrhcea 
or  prostatorrhoea.  The  thoughts  are  concentrated  on  the 
sexual  trouble  ;  headache,  listlessness,  loss  of  memory  and 
a  dull,  heavy  backache  supervene,  and  the  man  gradually 
drifts  into  a  wretched  sexual  neurasthenic. 


chapti:k  xi 
the  diagnosis  of  chronic  urethritis 

Bi^FORE  we  can  determine  the  line  of  treatment  it  is  wise 
to  adopt  in  any  i;iven  case,  an  exact  diagnosis  of  the  con- 
ditions present  must  be  made.  The  following  questions 
require  to  be  answered  : 

1.  Where  is  the  seat  of  the  inflammation  ?  Is  it  in  the 
anterior,  the  posterior,  or  in  both  portions  of  the  urethra  ? 

2.  Is  the  inflammation  limited  to  the  mucous  membrane, 
or  has  it  extended  to  the  deeper  structures  ? 

In  order  to  answer  these  questions,  a  thorough  and 
methodical  examination  of  the  patient  is  necessary,  and  I 
have  indicated  below  the  lines  on  which  such  an  examina- 
tion may  proceed.  It  must,  however,  be  understood  that 
to  complete  the  whole  several  examinations  are  necessary. 

1.  Tlic  liistory  of  the  illness  and  of  the  symptoms  complained 
of  is  to  be  carefully  noted,  especially  with  reference  to  the 
date  of  the  first  infection,  the  severit}'  and  duration  of 
acute  symptoms,  the  presence  or  absence  of  complications, 
and  the  history  of  relapses  or  reinfections. 

A  careful  inspection  and  palpation  of  the  penis, 
perina^um,  and  testicles,  should  be  made,  in  order  to 
determine  the  presence  or  absence  of  such  conditions  as 
balanitis,  urinary  fistulai,  periurethral  inflammation,  epi- 
didymitis, or  any  other  complication. 

2.  A   minute  examination  of  the  urine  is  also  to  he  jnade. 

74 


The  Diagnosis  of  Chronic  Urethritis        75 

The  morninf;  urine  must  be  diviflcd  into  two  |)oti)oii..  If 
the  first  quantity  contains  threads  and  the  sccf;nd  is  clear, 
the  anterior  urethra  only  is  affected ;  if  both  contain 
threads,  the  urethritis  extends  to  the  posterior  also. 

This  test,  however,  is  open  to  two  frdlacies  :  fa)  It  does 
not  distinguish  between  a  urethritis  limited  to  the  posterior 
urethra  and  one  affecting  botJi  portions  of  the  urethra ;  and 
(6)  it  fails  in  those  cases  of  posterior  urethritis  where  the 
secretion  is  so  scanty  that  it  does  not  regurgitate  into  the 
bladder.  To  meet  these  difficulties,  one  or  both  of  the 
following  devices  may  be  adopted  : 

{a)  The  Irrigation  of  the  Anterior  Urethra. — This  pro- 
cedure, the  details  of  which  have  been  described,  is  for 
most  cases  the  simplest  and  the  best.  If  the  irrigation 
fluid  returns  clear  and  free  from  pus  or  threads,  and  the 
urine  subsequently  passed  is  cloudy,  the  inflammation  is 
limited  to  the  posterior  portion.  If  there  are  threads  in 
the  irrigating  fluid  and  none  in  the  urine,  the  inflammatory 
condition  is  confined  to  the  anterior  portion.  And  if  there 
are  threads  in  both  fluids,  the  inflammation  is  present  in 
both  portions  of  the  urethra. 

{h)  The  Injection  of  the  Methylene  Blue.  —  Kromayer, 
instead  of  irrigating,  injects  a  solution  of  methylene  blue 
into  the  anterior  portion  of  the  urethra  by  means  of  an 
ordinary  urethral  syringe.  The  patient  is  then  allowed  to 
micturate,  when  all  the  threads  and  pus  cells  originating 
from  the  anterior  will  appear  stained  with  blue  ;  those 
from  the  posterior  will  be  unstained. 

3.  Microscopic  Examination  of  the  Secretion. — In  addition 
to  the  macroscopic  examination  already  referred  to,  it  is 
necessary  to  examine  the  secretion  and  urinar}^  threads 
more  closely  under  the  microscope,  for  by  this  means  it  is 
possible  to  determine  the  stage  of  the  inflammation,  and 
to  gauge  the  effect  of  the  treatment.     The  composition  of 


76      Treatment  of  Gonorrhoea  in  the  Male 

tlic  threads  will  be  seen  to  vary  as  the  disease  progresses. 
In  the  earlier  stages  the  threads  are  formed  principally  of 
pus  cells,  and  gonococci  are  numerous.  At  a  later  stage 
the  pus  cells  are  largely  replaced  by  squamous  epithelium, 
and  the  gonococci  are  met  w  itli  in  sjiaring  numbers,  and 
are  frequently  absent  from  the  secretion  for  days  together. 
This  frequent  absence  of  the  specific  micro-organism  is  a 
point  of  much  interest  and  practical  importance,  more 
especialh'  in  determining  whether  or  not  the  disease  is 
cured. 

In  examining  for  gonococci  in  chronic  urethritis,  the 
following  points  are  to  be  noted:  {a)  The  cocci  are  seldom 
present  in  large  numbers,  and  tend  to  diminish  in  number 
as  time  goes  on.*  (b)  The  cocci  are  generally  extracellular, 
(c)  Long  after  they  have  disappeared  from  the  urinary 
threads  and  sediment  they  may  be  detected  in  the  secre- 
tion expressed  by  massage  from  the  prostate  and  other 
urethral  glands.  (d)  When  the  cocci  are  apparently 
absent,  a  mechanical  or  chemical  irritation  of  the  urethra 
will  often  cause  them  to  reappear  in  large  numbers.  At 
such  times  the  cocci  are  found  within  the  pus  cells,  as 
in  the  acute  stage,  {e)  Not  infrequently  other  bacteria, 
bacilli,    and    cocci    are    found    in    the    secretion,    either 

*  The  following  statistics,  published  Ijy  Coll,  1891,  show  the 
tendency  of  the  gonococci  to  disappear  with  the  duration  of  the 
disease  : 

Percentage  of  Cases  in 
Duration  of  Disease.  which  Gonococci 

svere  Present. 
Fourth  to  fifth  week        -  .  .  47 

Sixth  week  ....  38 

Seventh  week      -  -  -  -  31 

Second  month     -  -  -  -  20 

Third  month        ...  -  17 

Sixth  month         ...  14 

One  year  -  -  -  14 

Two  years  ....  5 

Three  years         ...  2"5 

Vive  years  ....  — 


The  Diagnosis  of  Chronic  Urethritis        "j"] 

associated  with  the  gonococcus  or  not.  '11k:  presence 
of  such  bacteria  is  due  to  a  secondary  infection,  ;u)d  is 
of  no  special  significance  (Fig.  14).  (/)  ^^y^  S(;ine  cases 
the  gonococci  entirely  disappear,  and  however  carefully 
the  secretion  be  examined,  the  specific  micro-organism 
cannot  be  detected.  Here  it  must  be  assumed  that  the 
gonococci  have  died,  though  the  inflammatory  changes 
they  gave  rise  to  continue.  It  may  here  be  remarked 
that   the   detection   of    gonococci    in    the    chronic    stage 


i^- 


V 


\i'''f'(i<, 


i» 


Fig.  14. — Chronic  Gonorrhceal  Pus,  showing  Secondary  Infection 
WITH  A  Short,  Slender  Bacillus. 

of  the  disease  demands  considerable  bacteriological 
experience. 

Neisser  divides  chronic  gonorrhoea  into  three  phases  : 
(a)  Urethritis  chronica,  with  gonococci  present  in  the 
secretion  or  in  the  threads  ;  (6)  a  mixed  secondary  infec- 
tion, when  the  secretion  shows  a  large  number  of  different 
bacilli  and  cocci,  either  associated  with  the  gonococcus  or 
not ;  (c)  an  aseptic  urethritis,  when  micro-organisms  are 
no  longer  found. 

4.  The  next  step  in  tJic  examination  of  the  patient  is  to 
ascertain  it'hether  the  glands  of  the  prostate  are  inflamed 
or  not. 


7^       Treatment  of  Gonorrhoea  in  the  Male 

This  is  dctcnniiuJ  in  the  following  in.imicr :  The 
patient  is  instructed  to  pass  into  two  glasses  the  greater 
pari  of  his  urine,  which  has  been  allowed  to  collect  in  the 
bladder  for  some  hours.  The  surgeon  then  gently  massages 
the  prostate  from  the  rectum,  and  in  so  doing  expresses 
into  the  urethra  the  contents  of  the  prostatic  glands  and 
ducts.  The  remaining  portion  of  urine  is  then  passed 
into  a  third  glass,  and  is  examined  for  threads,  pus  cells 
and  cocci. 

Another  method  of  obtaining  the  prostatic  secretion  is 
to  direct  the  patient  to  empty  the  bladder,  which  is  then 


Fig.  15. 

filled  with  boracic  lotion.  The  prostate  is  then  massaged, 
and  the  patient  instructed  to  empty  the  bladder  again. 
Any  pus  cells  or  threads  seen  in  the  boracic  fluid  can 
have  come  only  from  the  prostatic  glands.  The  prostate 
is  massaged  either  by  the  finger,  protected  by  a  rubber 
glove,  or  by  some  suitable  instrument,  such    as    Feleki's 

(Fig.  15)- 

The  condition  of  the  bladder  and  seminal  vesicles  should 
also  be  ascertamed.  For  details  as  to  the  examination  of 
these  organs  the  reader  is  referred  to  pp.  127  and  124 
respectively. 

5.    Having   dctcriiiincd    the   scat    <>/  the    iiiJJaimiiation,    it 


The  Diagnosis  of  Chronic  Urethritis        79 

]>ecoines   necessary    to    ascertain    whether  it  is   limited   to   the 
mucous  membrane  or  has  extended  to  the  deeper  structures. 

In  order  to  do  this  an  '  acorn-headed  '  black  gum  bougie 
(Fig.  16)  of  as  large  a  size  as  the  meatus  will  admit  (say  a 
No.  12  or  14  English)  is  gently  passed  down  the  whole 
length  of  the  urethra.  If  the  head  of  the  bougie  passes  over 
an  inflamed  area,  a  twinge  of  pain  is  felt  by  the  patient, 
which  ceases  as  soon  as  the  head  has  passed  beyond  the 
affected  spot,  but  is  felt  again  when  the  head  passes  over 
it  as  the  bougie  is  being  withdrawn.  By  noting  these 
sensitive  spots,  the  seat,  and  roughly  the  extent,  of  the 
inflammation  may  be  determined.  Moreover,  the  passage 
of  a  large  acorn-headed  bougie  proves  the  absence  of  any 


Fig.  16. 


decided  stricture  of  the  urethra,  to  ascertain  which  is  of 
the  greatest  importance. 

But  it  must  be  observed  that  although  this  bougie  is  a 
useful  instrument  in  helping  one  to  form  the  diagnosis,  its 
usefulness  is  limited.  It  has  been  seen  that  the  meatus  is 
the  narrowest  and  least  elastic  portion  of  the  urethra,  con- 
sequently a  considerable  contraction  of  the  inflamed  canal 
may  take  place  without  the  calibre  of  the  lumen  falling 
below  that  of  the  meatus.  Such  contractions  Otis  desig- 
nated 'wide  strictures.'  It  is  obvious  that  in  such  cases 
it  would  be  impossible  to  detect  the  narrowing  b}^  means 
of  the  bougie.  The  degree  of  contraction  in  such  cases 
may,  however,  be  determined  by  the  use  of  the  urethro- 
meter.  This  instrument,  when  introduced  into  the  urethra, 
can  be  expanded  at  will,  the  degree  of  expansion  being 
indicated  by  a  pointer  on  a  dial.  The  figures  on  the  dial 
correspond  to  the   French,   or    Charriere's,  scale   for   all 


^"^o      Treatment  of  Gonorrhoea  in  the  Male 


urethral  instruments.     In  this  scale  each  number  represents 
an  increase  of  \  millimetre  in  diameter — i.e.,  No.  i  boui/ie 


Fig.  17. 


Fig.  18. 


Fig  19. 


has  a  diameter  of  ;\  millimetre ;  No.  3=1  millimetre ; 
No.  30  =  10  millimetres,  etc.  Of  this  instrument  three 
forms  are   illustrated   above,   Fig.   17    being    Otis's   well- 


The  Diagnosis  of  Chronic  Urethritis        ^ ' 

known  instrument,  the  lirst  that  was  devised  for  the 
purpose.  Fig.  18  is  Weir's;  Fig.  ig  is  Kolhnann's.  These 
latter  are  of  later  date,  and  have  the  advantage  of  being 
less  fragile. 

The  dilatability  of  the  normal  urethra  in  its  various  parts 
has  already  been  given  (see  p.  4).  Any  inflammatory  in- 
filtration of  the  urethra  renders  it  less  and  less  dilatable, 
according  to  the  depth  to  which  the  infiltration  has  pene- 
trated and  its  advancement  towards  fibrosis.  By  carefully 
comparing  the  amount  of  dilatation  which  the  urethra  will 
admit  with  its  normal  dilatability,  a  very  good  idea  of  the 
extent  and  depth  of  the  inflammation  can  be  arrived  at.  In 
use  the  closed  urethrometer  is  passed  down  the  length  of  the 
canal,  and  the  dilatability  of  each  portion  of  the  urethra  is 
tested  as  the  instrument  is  gradually  withdrawn.  The 
expansive  terminal  of  the  urethrometer  is  covered  with  a 
thin  indiarubber  capsule  to  protect  the  delicate  mucous 
membrane  from  injury.  This  instrument  is  of  the  greatest 
value  as  an  aid  to  exact  diagnosis. 

Lastly,  the  urethral  mucous  membrane  should  be 
examined  by  means  of  the  endoscope.  As  a  full  de- 
scription of  the  uses  of  this  valuable  instrument  would 
be  impossible  in  the  space  at  command,  a  brief  account 
only  of  it  can  be  given.*  By  its  use  it  is  possible  minutely 
to  inspect  the  inflamed  surface  of  the  urethra,  and  so 
to  gain  a  clearer  knowledge  of  its  condition  than  by  any 

*  For  a  full  account  of  the  urethroscope  the  reader  is  referred  to 
the  following  works  :  Fenwick,  Hurry,  'The  Electrical  Illumination  of 
the  Bladder  and  Urethra";  Griinfeid,  'Die  Endoskopie  der  Harnrohre 
und  Blase,'  Stuttgart,  1881;  De  Keersmaecker  and  \'erhoogen, 
'  L'Urdthrite  Chronique  dOrigine  Gonococcique,'  Bruxelles,  1898; 
Oberljinder,  '  Lehrbuch  der  Urethroskopie,'  Leipzig,  1893;  Ober- 
Ijinder  and  KoUmann,  '  Die  Chronische  Gonorrhoea  der  ^lannlichen 
Harnrohre,'  Leipzig,'  1905;  A'alentine,  '  The  Irrigation  Treatment  of 
Gonorrhcea,'  New  York. 

6 


<^2       Treatment  of  Gonorrhoea  in  the  Male 


other  means ;  but  it  is  neither  necessary  nor  ndvisablc 
to  use  it  in  e\ery  case.  Its  chief  value  Hes  in  the  help 
it  affords  in  the  observation  and  treatment  of  the  later 
chronic  stages  of  the  disease.  It  should  never  be  used  in 
the  acute  stage. 

In  its  simj)lest  form  the  endoscope  consists  solely  of  a 


O^^ 


=o 


Fig.  20. 

straight  metal  tube,  5  or  6  inches  in  length,  having  a 
funnel-shaped  opening  at  one  end  (Fig.  20).  The  tube 
being  introduced  into  the  urethra,  the  light  is  reflected 
down  the  funnel  end  by  means  of  a  mirror.  The  illumina- 
tion, however,  is  so  imperfect  that  the  instrument  in  this 
form    is    of  but  limited  value.      To   correct   this   several 


Fig.  21. 

modifications  ha\e  been  devised,  of  which  Schall's  or 
\'alentine's  is  to  be  preferred.  Schall's  instrument 
(Fig.  21)  is  a  modification  of  Casper's  endoscope,  and 
is,  I  think,  the  best  form  of  indirect  illumination,  the  light 
from  a  small  incandescent  lamp  being  reflected  by  means 
of  a  prism  down  the  urethral  tube. 


The  Diagnosis  of  Chronic  Urethritis        H3 

Valentine's  instrument  (l^'i^.  22)  is  the  mr>st  efjnvenient 
form  of  direct  illumination.  Here  the  source  of  light  is 
a  minute  incandescent  lamp,  mounted  at  the  end  (>{  a 
rigid  metal  wire,  that  can  be  passed  down  the  tuhe,  thus 
directly  illuminating;  the  portion  of  the  meml^rane  under 
observation.  This  instrument  gives  a  sharper  illumina- 
tion, but  it  has  the  disadvantage  of  being  more  fragile, 
and  of  possibly  unduly  heating  the  mucous  membrane,  if 
the  observer  be  too  deliberate  in  his  examination. 

There  are  several  other  urethroscopes  of  considerable 


^^ 


Fig.  22. 

merit  upon  the  market,  but    the  two   I    have    described 
above  are  generally  regarded  as  the  best  forms. 

In  using  the  endoscope  the  patient  should  lie  on  a  high 
table,  or,  better,  recline  in  a  gynaecological  examination 
chair  in  the  lithotomy  position,  the  surgeon  sitting  in  front. 
The  largest  tube  that  the  meatus  will  admit  must  be 
selected,  as  the  illuminated  area  is  necessarily  small.  If 
the  urethra  is  very  sensitive,  a  3  per  cent,  solution  of 
cocaine  may  with  advantage  be  previously  injected. 
Then  the  tube,  the  end  of  which  is  closed  with  an  ob- 
turator or  plug,  and  being  well  lubricated  with  glycerine, 
is  gradually  introduced.  In  order  to  pass  it  into  the 
posterior  urethra,  the  ocular  end  of  the  instrument  must 
be  w^ell  depressed,  as  the  tube  passes  under  the  symphysis 

6—2 


84       Treatment  of  Gonorrhoea  in  the  Male 

pubis.  The  obturator  is  now  withdrawn,  the  himp  is 
passed  down  the  tube,  and  tlie  Hght  is  switched  on,  when 
the  mucous  membrane  can  be  examined  little  b\'  httle  as 
the  tube  is  gently  drawn  out. 

All  secretion,  blood  or  urine,  must  be  carefully  mopped 
up,  each  portion  of  the  membrane  being  cleaned  and 
inspected  as  it  comes  in  view.  For  cleaning  purposes  it 
is  convenient  to  use  thin  wooden  strips,  having  a  little 
cotton-wool  wrapped  round  one  end. 

In  the  normal  condition,  except  during  mic^turition,  the 


Fig.  23.— Membranous  Portion  of 
Normal  Urethra  as  seen 
through  the  endoscope,  show- 
ING Small  Round  Central 
Figure  with  Numerous  Fine 
Radiating  Folds. 


Fig.  24.  —  Normal  Prostatic 
Urethra,  showing  the  An- 
terior Portion  of  the  Caput. 


walls  of  the  urethra  are  in  contact,  lying  in  longitudinal 
folds.  The  passing  of  the  urethroscope  separates  the 
walls ;  but  as  it  is  being  withdrawn  they  fall  together 
again,  at  a  short  distance  from  the  end  of  the  tube,  in 
the  form  of  a  funnel,  the  folds  radiating  from  a  central 
point,  which  has  much  the  appearance  of  a  sphincter,  and 
is  called  'the  central  figure'  (Fig.  23). 

In  the  normal  condition  of  the  prostatic  urethra  the 
mucous  membrane  is  smooth  and  of  deep  red  colour. 
As  the  tube  is  withdrawn,  the  mucous  membrane  becomes 
paler,  and  a  rounded  prominence  appears  at  the  lower 
edge  of  the  tube ;  this  prominence  represents  the  caput 
gallinaginis  (Figs.  24  and  25).     As  the  tube  is  still  further 


The  Diagnosis  of  Chronic  Urethritis         ^S 


withdrawn  tlu:  caput  disappears  frf)m  view,  and  the  mem- 
branous poilion  is  inspected.  Tiiis  is  generally  p.aler  in 
colour  than  the  prostatic,  and  the  central  figure  is  more 
regular.  In  the  bulbous  part  the  folds  of  mucous  mem- 
brane arc  larger,  and  the  central  figure  appears  as  a 
vertical  fissure  (Fig.  26),  and  at  times  the  openings  of 
Cowper's  glands  can  be  seen  in  the  floor.  In  the  penile 
part  the  opening  of  the  glands  of  Littre  and  Morgagni  can 
be  seen  in  the  upper  and  lower  walls  of  the  urethra.     In 


Fig.  25,  —  Normal  Prostatic 
Urethra,  showing  the  Caput 
Gallinaginis. 


Fig.  26. — Normal  Urethra  in 
THE  Middle  of  the  Bulbous 
Portion.  Central  Figure 
Vertical. 


the  glans  the  membrane  has  almost  lost  its  red  colour,  and 
the  round  '  central  figure  '  has  become  triangular. 


The    Appearance    of   the    Chronically    Inflamed 
Urethra. 

Two  forms  of  inflammatory  lesions  can  be  seen  by  the 
endoscope  in  chronic  urethritis.  The  first  is  that  which 
was  described  when  speaking  of  the  morbid  anatomy  of 
the  condition  as  consisting  of  localized  small-celled  infil- 
trations of  the  subepithelial  tissues,  causing  swelling  and 
hypersemia  of  the  mucous  membrane.  This  represents 
the  '  soft  infiltration  '  of  Oberlander,  and  is  the  earl}-  stage 
of  the  chronic  gonorrhoeal  process.  The  second  group 
of  pathological  changes  forms  what  Oberlander  calls  the 
'  hard  infiltration.'     It  includes  all  the  inflammatory  pro- 


86      Treatment  of  Gonorrhoea  in  the  Male 

cesses  by  which  the  small-celled  soft  inhltration  gradually 
passes  into  tirm  hbroid  scar  tissue,  which  reaches  its 
highest  development  in  the  formation  of  a  stricture.  The 
conversion  of  a  soft  infiltration  area  into  firm  cicatricial 
tissue  is  a  gradual  process,  all  the  phases  of  which  can  be 
observed  by  the  urethroscope. 

Soft  Small-celled  Infiltration. 

In  the  soft  small-celled  infiltration  in  its  most  typical 
stage  the  mucous  membrane  is  hyperamic  and  redder 
than  normally.  Its  epithelium  is  oedematous,  dull,  and 
loosened,  so  that  it  is  readily  detached,  and  may  be  alto- 
gether absent  in  places,  leaving  small  erosions  which  bleed 
on  being  touched  by  a  probe.  In  consequence  of  the 
swelling  and  oedema  of  the  mucous  membrane,  the  longi- 
tudinal folds,  into  which  the  urethra  is  normally  thrown 
when  the  passage  is  not  distended,  are  coarser  and  less 
numerous.  Instead  of  seeing  several  fine  folds  radiating 
from  the  central  figure,  as  normally,  three  or  four 
thickened  folds  press  forward  into  the  lumen  of  the 
endoscopic  tube.  In  the  penile  portion  the  openings 
of  the  crypts  of  Morgagni  are  seen  to  be  reddened  and 
swollen,  whilst  in  the  prostatic  urethra  the  principal 
changes  are  grouped  around  the  caput  gallinaginis,  which 
is  swollen  and  hyperaemic,  and  projects  into  the  tube, 
looking  not  unlike  a  ripe  raspberry. 

Hard  Infiltration. 

Pari  passu  with  the  gradual  cicatrization  of  the  soft 
small-celled  infiltration,  the  hyperemia,  turgescence,  and 
elasticity  of  the  affected  mucous  membrane  diminish. 
The  red,  angry-looking  membrane  becomes  paler  and 
paler   as  the  infiltration  hardens.       The    epithelium    be- 


The  Diagnosis  of  Chronic  Urethritis        H7 

comes  thicker  and  less  transparent ;  frequently  it  takes 
on  a  curious  stippled  appearance,  and  may  undergo  so 
marked  a  proliferation  as  to  give  rise  to  a  form  of  pachy- 
dermia. The  longitudinal  folds  of  the  mucous  membrane 
gradually  disappear,  becoming  both  less  marked  and  less 
numerous  (Fig.  27).  In  the  later  stages  of  the  disorder, 
where  considerable  contraction  of  the  inflammatory  area 
has  taken  place,  these  folds  may  entirely  disappear,  so 
that  the  urethra  as  seen  through  the  endoscope  appears 
as  a  stiff,  inelastic  tube  with  smooth  pale  walls. 


Fig.  27. — Appearance  of  Chronically-Inflamed  Urethra,  showing 
AN  Old  Infiltration  Area  in  the  Penile  Portion.  Central 
Figure  Gaping,.  Longitudinal  Folds   less  Numerous   and    less 

Marked  than  Normally. 

It  must  be  remembered  that  the  normal  mucous  mem- 
brane varies  greatly  in  colour  according  to  its  vascularity 
and  other  circumstances,  so  that  too  much  importance 
must  not  be  attached  to  a  slight  alteration  in  its  tint. 
The  use  of  cocaine,  too,  causes  a  contraction  of  the 
vessels,  and  consequent  paleness  of  the  surface.  Con- 
siderable experience  is  therefore  necessary  in  order  rightly 
to  interpret  the  endoscopic  picture. 

The  Urethra  as  it  appears  during-  the  Process  of 
Healing'. 

The  gradual  healing  of  the  inflammatory  process  under 
appropriate  treatment  can  be  readily  observed  b}^  means 
of  the  endoscope.     The  mucous  membrane  covering  the 


SS       Treatment  of  Gonorrhoea  in  the  Male 

soft  intiltration  f:;radually  loses  its  anj,'ry  red  colour,  and 
regains  its  n(.)rmal  appearance.  As  the  swelling  of  tlu' 
membrane  dies  down  the  longitudinal  folds  become  liner 
and  more  numerous,  and  the  lining  epithelium  regains  its 
bright,  transparent,  glistening  appearance.  It  is  around 
the  crypts  and  follicles  of  the  urethra  tiiat  the  inflamma- 
tion is  seen  to  linger  longest.  For  some  time  after  the 
rest  of  the  urethra  has  regained  its  healthy  appearance 
a  zone  of  inflammation  may  be  seen  to  surround  the 
openings  of  the  large  lacunae  and  glands,  from  the  mouths 
of  which  a  muco-purulent  secretion  may  occasionally  be 
expressed. 

Where  the  inflammatory  lesion  has  proceeded  to  the 
development  of  cicatricial  fibrous  tissue  (hard  infiltration) 
the  return  of  the  mucous  membrane  to  its  normal  appear- 
ance is  naturally  slower  and  less  complete.  Although  to 
a  large  extent  it  regains  its  healthy  colour,  yet  in  the 
immediate  neighbourhood  of  the  infiltration  the  mem- 
brane remains  permanentK-  paler  in  colour.  The  epi- 
thelial lining  becomes  smoother  and  healthier,  but  does 
not  always  recover  its  normal  glistening  appearance, 
though  its  excessive  proliferation  disappears.  After  com- 
plete healing  of  the  inflammation  small  whitish-looking 
scars  may  be  seen  in  the  mucous  membrane,  especially 
in  the  neighbourhood  of  the  bulb  and  around  the  large 
mucous  follicles. 


CHAPTER  XII 

THE  TREATMENT  OF  CHRONIC  URETHRITIS 

It  has  already  been  indicated  that  cHnically  all  cases  of 
chronic  urethritis  can  be  divided  into  two  groups : 

1.  The  more  recent,  or  the  subacute,  where,  in  addition 
to  the  localized  areas  of  cellular  infiltration,  there  is  a 
more  or  less  general  catarrhal  inflammation  of  the  mucous 
membrane,  and  the  presence  of  mucus  as  well  as  threads 
may  be  traced  in  the  urine. 

2.  The  inveterate  or  circitmscribed,  in  which  there  is  no 
general  catarrh,  the  whole  trouble  being  confined  to 
definite  localized  portions.  This  group  may  again  be 
divided  into  (a)  those  that  affect  only  the  mucous  mem- 
brane, and  (6)  those  that  affect  the  submucous  tissue  also. 

Each  of  these  forms  requires  a  different  mode  of  treat- 
ment. In  the  recent  variety,  attention  must  first  be 
directed  to  subduing  the  general  catarrhal  condition  by 
means  of  weak,  astringent  solutions,  leaving  the  treatment 
of  the  localized  areas  of  cellular  infiltration  till  this  has 
been  accomplished. 

In  the  superficial  circumscribed  variety  the  localized  in- 
filtration area  may  be  treated  b}'  means  of  strong  astrin- 
gent and  caustic  remedies,  applied  directh-  and  solely  to 
the  affected  spot. 

In  the  deep  circumscribed  form,  in  addition  to  surface 
applications,  pressure  and  dilatation  must  be  tried,  in 
order  to  induce  absorption  of  the  deep  induration. 

S9 


QO       Treatment  of  Gonorrhoea  in  the  Male 

The  suggestions  as  to  hygienic  and  dietetic  measures 
and  internal  remedies  made  in  speaking  of  the  acute  form 
of  the  malady  (p.  41)  are  equally  applicable  to  the 
chronic  condition,  though,  owing  to  the  longer  duration  of 
the  treatment,  it  will  probably  be  found  necessary  to  relax 
some  of  the  more  stringent  regulations  as  to  diet,  etc. 
Therefore  we  may  now  proceed  at  once  to  the  considera- 
tion of  the  special  local  treatment  of  the  disease  in  its 
various  chronic  forms. 

Subacute  Urethritis. 

The  first  aim  must  be  to  subdue  the  general  catarrhal 
condition  of  the  mucous  membrane,  leaving  the  areas  of 
cellular  infiltration  to  be  treated  later.  Experience  has 
shown  th;it  the  best  remedy  to  effect  this  is  the  irrigation 
of  the  canal  with  mild  astringent  solutions.  For  this 
purpose  the  ordinary  small  urethral  syringe  is  rarely  suit- 
able, for,  as  has  been  already  explained,  the  anterior 
urethra  is  seldom  solely  affected  in  chronic  gonorrhoea, 
the  inflammation  generally  extending  to  the  posterior 
portion  ;  consequently  to  use  the  small  syringe  for  injec- 
tion would  probably  leave  a  large  portion  of  the  inflamma- 
tion untouched.  This  is  one  of  the  commonest  errors  in 
the  treatment  of  gleet.  It  is  essential  to  success  that  the 
irrigation  fluid  be  brought  into  contact  with  the  whole  of 
the  walls  of  the  urethra.  This  may  be  accomplished,  as 
has  already  been  shown  in  the  treatment  of  the  acute 
stage  of  posterior  urethritis,  by  gradually  increasing  the 
pressure  of  the  fluid  injected  at  the  meatus  by  means  of 
the  irrigator  or  large  syringe  until  it  is  sufficient  to  over- 
come the  spasm  of  the  compressor  urethrae  (Janet's 
irrigation).  Another  method  is  to  inject  the  fluid  by 
means  of  a  soft  rubber  catheter  passed  into  the  posterior 
urethra  (Diday's  irrigation).  It  is  well  to  select  that 
method  which    causes   the    patient   the  least  discomfort. 


The  Treatment  of  Chronic  Urethritis 


9' 


Sometimes  it  is  the  one,  sometimes  tlie  other.  If  it  is 
important  to  avoid  :ill  unnecessary  irritutifii  to  the;  urethra, 
it  is  especially  so  as  long  as  the  presence  of  mucus  in  the 
urine  shows  that  a  j:^eneral  catarrh  exists. 

The  Injection  Fluid. — Experience  has  shown  that  the 
organic  combinations  of  silver,  as  protargfjl  and  argonin, 
have  not  the  same  value  in  the  chronic  that  they  have  in 
the  acute  forms.  Consequently,  as  a  rule,  the  simple 
nitrate  of  silver  is  to  be  preferred,  which,  when  freely 
diluted  (I  in  I0,000  to  i  in  500),  is  generally  the  most 
useful  injection.  Other  solutions  valuable  at  this  stage  of 
the  disease  are  permanganate  of  potash  (i  in  to,ooo  to  i 
in  2,000)  and  sulphate  of  zinc  (i  in   1,000  to  i  in  500). 


Fig.  28. 


Neither  Janet's  nor  Diday's  irrigation  can  properly  be 
administered  by  the  patient  himself.  Therefore,  if  for  any 
reason  he  is  unable  to  have  the  irrigation  frequently  per- 
formed for  him,  other  measures  must  be  adopted.  If  the 
patient  is  intelligent,  I  give  him  a  large  wound  syringe, 
holding  4  ounces,  and  fitted  with  an  olive-shaped  end 
(Fig.  28).  I  instruct  him  to  fill  the  syringe  with  the 
lotion,  and  to  inject  the  contents  a  la  Janet  into  the 
bladder.  He  seldom  finds  an}-  difficulty  in  doing  this. 
One  or  more  syringefuls  ma}'  be  injected.  The  irrigation 
is  to  be  performed  once  every  day,  preferably  at  night  (the 
strength  of  the  solution  being  gradually  increased),  until 
the  urine  becomes  clear  and  free  from  mucus,  showing 
only  the  presence  of  urethral  threads.  The  disorder  then 
passes  into  the  second  classification. 


92       Treatment  of  Gonorrhoea  in  the  Male 

The  Inveterate  or  Circumscribed  Variety. 

We  will  first  consider  tlie  superficial  form,  where  the 
mucous  membrane  alone  is  involved,  and  where  there  is 
neither  a  narrowing  of  the  urethra  nor  an  exten- 
di sion  of  the  intiammation  to  the  prostate.  A 
powerful  astringent  may  now  be  directly  applied 
to  the  affected  spot,  and  to  it  only.  This  may  be 
done  in  one  of  se\'eral  ways.  There  is,  however,  no 
better  instrument  for  this  purpose  than  the  endo- 
scope. Having  carefully  exposed  the  inflamed 
area,  a  strong  solution  (i  per  cent,  to  lo  per  cent.) 
of  nitrate  of  silver  or  sulphate  of  copper  ma\-  be 
applied  by  means  of  a  brush  or  small  swab,  all 
excess  of  fluid  being  carefully  mopped  up.  Instead 
of  the  endoscope,  Guyon's  or  Ultzmann's  syringe 
may  be  used.  In  every  case  the  instrument  must 
be  lubricated  with  glycerine,  and  not  with  oil. 

These  strong  astringent  remedies  should  not  be 
applied  oftener  than  every  second  or  third  day. 
In  the  intervals  the  urethra  may  be  irrigated  by 
Janet's  or  Diday's  method  with  a  mild  astringent 
fluid  of  permanganate  of  potash  or  sulphate  of 
zinc.  Two  golden  rules  are  to  be  observed  in  the 
use  of  these  injections:  Always  begin  with  weak 
solutions,  proceeding  gradually  to  the  stronger 
ones,  and  allowing  the  reaction  which  follows  the 
application  to  completely  die  down  before  repeat- 
ing the  process. 

It  is  occasionally  of  advantage  to  apply  a  remedy 

which  will  have  a  more  prolonged  and  continuous 
Fig.  29.  .  ,  ,  ....  .  J 

action  than  the  watery  mjections  just  mentioned. 

With    this   object  in  view,   numerous  soluble    medicated 

bougies  have  been  devised  which,  being  introduced  into  the 


The  Treatment  of  Chronic  Urethritis        93 

urethra,  arc  allowed  slowly  to  dissolve.  'Ilieir  use,  how- 
ever, has  not  Ijcen  followed  l»y  iiiiicli  success,  and  as  they 
unnecessarily  irritate  the  healthy  prjrtion  of  the  mucous 
membrane,  they  are  not  to  be  recommended.  Where  the 
more  continuous  action  of  the  remedy  is  desirable,  the 
drug  may  be  incorporated  with  huHjline,  and  applied 
directly  to  the  inflamed  area  by  means  of  an  ointment 
introducer  (Fig.  29).  The  lanoline  ointment  spreads  over 
the  mucous  membrane  and  tenaciously  adheres  to  it,  and 
is  not  readily  removed  by  micturition.  A  useful  formula 
for  such  an  ointment  is  nitrate  of  silver  i  to  5,  lanoline 
50,  vaseline  50. 

Lastly  may  be  considered  that  form  of  the  disorder  in 
which  the  inflammation  has  penetrated  deeply  into  the 
tissues,  producing  an  infiltration  of  the  connective  tissue. 

The  aim  here  must  be  to  try  to  induce  absorption  of  the 
deep-seated  induration  by  means  of  pressure  and  dilata- 
tion ;  but  the  mucous  membrane  covering  the  deep  indura- 
tion being  inflamed,  it  also  requires  treatment,  as  explained 
in  the  tw^o  preceding  sections. 

The  value  of  the  dilatation  of  the  urethra  in  assisting  the 
absorption  of  an  induration  has  long  been  recognised,  but 
it  has  already  been  pointed  out  that  the  mere  occasional 
passage  of  a  bougie  (a  means  usually  resorted  to)  is  wholly 
inadequate.  To  obtain  the  full  benefit  of  the  treatment 
the  dilatation  must  be  carried  out  on  a  rational  and 
systematic  plan.  The  earlier  stages  of  dilatation  are  best 
effected  by  means  of  steel  bougies,  beginning  with  a  low 
number  and  gradually  passing  on  to  the  higher.  But  the 
bougies  in  common  use  are  not  well  suited  to  the  purpose, 
as  they  are  not  sufficiently  large,  nor  is  their  shape  the 
most  desirable.  For  dilating  the  anterior  urethra,  short 
straight  c\'lindrical  bougies  are  best.  For  the  whole  of 
the    urethra,  the    conical    bougies   of  Dittel    or  those  of 


94       Treatment  of  Gonorrhoea  in  the  Male 

Ciuyon  are  most  convenient.     Instead  of  stopping  at  the 

useof  a  No.  12  English,  as  is  general!}-  done,  it  is  needful 

to  increase  the  size  up  to  18  or  20.     But  even  with  the  use 

of  these  large  bougies  the  urethra  cannot  be  thoroughly 

dilated,   for  the    largest    bougie    that    the   penile  portion 

when  stretched  to  the  uttermost  will  admit  is  too  small 

to  distend  either  the  bulbous  or  prostatic  portion.     The 

narrowness  of  the  meatus  may  be  overcome  b\'  an  incision, 

but  that  would  only  partially  help  us.     An  instrument  is 

needed  which,  like  the  urethrometer,  can  be  passed  through 

the  narrow  portion,  and  then  expanded  at  will.     Such  an 

instrument  is  provided  in  the  urethral  dilators*  of  Ober- 

liinder  (Fig.  30),  Kollnumn  (Figs.  31  and  32),  and  others. 

These  dilators  are  made  in  various  forms,  so  that  the  whole 

or  any  part  of  the  urethra  can  be  treated. 

The  dilators  of  Oberlander  when  in  use  are  covered 
with  a  thin,  tighth'-htting  indiarubber  sheath,  in  order 
to  prevent  the  mucous  membrane  being  caught  between 
the  two  arms  when  the  instrument  is  closed  prior  to  its 
withdrawal.  The  newer  instruments  of  Kollmann  are  so 
constructed  that  the  rubber  sheatii  is  unnecessary. 

The  dilator,  after  having  been  well  lubricated  with 
glycerine  and  tragacanth,  is  passed  down  to  the  affected 
portion  of  the  urethra,  and  then  by  means  of  the  screw 
slowly  expanded.  The  degree  of  expansion  is  indicated 
on  a  dial.  The  dilatation  must  be  very  gradual,  not  more 
than  I  millimetre  at  a  sitting,  and  must  be  stopped 
immediately  it  occasions  pain  ;  it  should  not  give  rise 
to  bleeding.  After  an  interval  of  seven  or  eight  days,  and 
when  all  reaction  has  died  down,  the  dilatation  may  be 
carried    to   a    fuller   degree.      After   each    dilatation    the 

*  These  urethral  dilators  are  made  in  \arious  forms.  Figs.  28 
and  29  represent  instruments  designed  to  dilate  the  anterior  urethra, 
Fig.  30  the  posterior,  and  Kig.  31  Ijotii  anterior  and  posterior. 


The  Treatment  of  Chronic  Urethritis 


95 


^1_ 

"^M^ 


Fig.  30.  Fig.  31 


Fig.  S3- 


urethra  must  be  irrigated  with  a  dikite  antiseptic,  such  as 
nitrate  of  silver  (i  in  5,000)  lotion.  In  the  interval 
astringent  injections,  Janet's  or  Dida\-'s,  are  to  be  used. 


96       Treatment  of  Gonorrhoea  in  the  Male 

If  tliese  instriiniciits  are  carefully  ami  reasonably  used, 
avoiding  all  attempts  to  unduly  hurry  the  process,  and 
always  abstaining  from  employing  them  during  the  inflam- 
matory reaction,  the}'  constitute  a  decided  advance  in  the 
treatment  i>f  the  later  stages  of  the  disease.  Not  only 
does  the  pressure  and  dilatation  assist  the  absorption  of 
the  inflammatory  induration,  but  it  squeezes  out  the 
contents  of  the  urethral  glands,  and  liberates  any  gonococci 
which  may  be  lurking  there. 

As  long  as  the  secretion  contains  numerous  gonococci 
instrumental  interference  of  any  kind  is  best  withheld, 
but  the  presence  of  a  few  is  not  in  itself  a  contra-indication 
for  treatment  by  dilatation. 

Recently  Lohnstein  has  suggested  that  the  irrigation 
should  be  performed  whilst  the  folds  of  the  mucous  mem- 
brane are  stretched  out  by  the  dilator.  For  this  purpose 
both  he  and  Kollmann  have  devised  special  instruments. 
Fig.  33  represents  Kollmann's  latest  improvement. 

The  combination  of  irrigation  and  dilatation  is  especially- 
indicated  where,  as  shown  by  the  urethroscope,  the  urethral 
glands  and  follicles  are  markedly  affected. 

It  is  advisable  in  all  cases  to  begin  the  dilatation  treat- 
ment with  the  use  of  the  bougies,  as  they  cause  less 
irritation  to  the  urethra  than  the  dilators  do.  If  the 
meatus  is  moderately  wide  the  passage  can  generally  be 
dilated  without  discomfort  up  to  No.  26  or  27,  and  often 
to  No.  30  (French  scale).  In  many  cases  it  is  unnecessary 
to  use  the  dilators  at  all,  as  the  degree  of  expansion 
obtained  by  the  large  bougies  is  sufficient  to  bring  about  a 
cure.  The  progress  of  the  case  should  be  controlled  from 
time  to  time  by  a  microscopic  examination  of  the  secretion 
and  the  use  of  the  urethroscope. 


The  Treatment  of  Chronic  Urethritis       97 

Summary  of  the  Treatment  of  Chronic  Urethritis. 

It  may  be  convenient  Ijriclly  t(j  snininari/(j  the  trf:a.trii(;nt 
which  has  been  advocated  in  the  i)recedinj^  pages. 

The  first  essential  is  the  formation  of  an  exact  diagnosis, 
so  that  the  extent  and  character  of  the  inflaiinnation  to  be 
treated  may  be  clearly  appreciated. 

In  the  absence  of  any  contra-indication,  such  as  an  acute 
complication,  the  treatment  is  begun  by  irrigating  the 
entire  urethra  (Diday's  method)  once  a  day  with  a  warm 
dilute  solution  of  nitrate  of  silver  (i  in  10,000)  or  of  per- 
manganate of  potash  (i  in  8,000).  If  this  is  well  tolerated, 
the  strength  of  the  solution  may  be  cautiously  increased  ; 
and  a  little  later  it  may  be  of  advantage  to  change  Diday's 
method  of  irrigation  for  the  more  powerful  one  of  Janet. 
The  beneficial  effect  of  this  treatment  is  seen  in  the  clear- 
ing of  the  urine  through  the  disappearance  of  the  cloud  of 
mucus  and  the  diminution  in  the  number  and  size  of  the 
urethral  threads.  Should  the  symptoms  point  to  the 
prostate  being  involved,  then,  in  addition  to  the  urethral 
irrigations,  this  gland  should  be  gently  massaged  two  or 
three  times  a  week.  As  the  urine  clears  under  this  treat- 
ment the  strength  of  the  irrigating  solutions  may  be 
increased.  When  the  urine  is  quite  clear  from  mucus, 
and  only  shows  the  presence  of  urethral  threads,  stronger 
solutions  (preferably  of  nitrate  of  silver  i  per  cent,  to 
10  per  cent.)  may  occasionally  be  applied  directly,  and  as 
far  as  possible  solely,  to  the  inflamed  areas  by  means  of 
the  urethroscope,  or  Guyon's  or  Ultzmann's  syringe. 

Should  the  instrumental  examination  of  the  urethra 
reveal  any  narrowing  of  its  lumen  or  other  indication  of 
the  involvement  of  the  submucous  tissues,  steps  must  be 
taken  to  restore  the  lumen  of  the  canal  and  to  induce 
absorption  of  the  induration.  ■  To  this  end  the  urethra 


9^^       Treatment  of  Gonorrhoea  in  the  Male 

should  be  systematically  dilated,  at  liist  by  means  of 
bougies,  and  later,  if  necessary,  by  some  form  of  dilator. 
Unless  the  narrowing  of  the  urethra  is  considerable — a 
true  stricture  bein^  present — the  dilatation  should  not  be 
begun  until  the  irrigation  treatment  has  subdued  the 
general  catarrhal  condition  of  the  mucous  membrane, 
leaving  the  urine  clear  and  the  secretion  free  from  gono- 
cocci.  The  dilatation  is  performed  about  once  a  week. 
.\fter  it  the  urethra  should  be  irrigated  with  a  very  weak 
astringent  antiseptic,  and  in  the  inlcr\als  Janet's  injections 
employed. 


PART  II. 
THE  COMPLICATIONS  OF  GONORRHCEA 

CHAPTER  I 

MINOR    COMPLICATIONS 

{Balanitis — Para-tirethral  Canals — Papillomata — Folliculitis 

Urethralis — Inflanimation  of  Cowper's  Gland — 

Lymphangitis  and  Lymphadenitis) 

Balanitis. 

Balanitis  is  the  term  applied  to  an  inflammation  of  the 
mucous  membrane  covering  the  glans  penis  and  lining 
the  prepuce. 

Although  balanitis  is  frequently  met  with  in  connection 
with  gonorrhoea,  it  is  not,  perhaps,  strictly  speaking,  a 
complication  of  that  disorder,  as  it  is  not  caused  by  the 
action  of  the  gonococcus,  and  frequently  arises  quite 
independently  of  it. 

Almost  any  kind  of  irritation  of  the  end  of  the  penis 
may  give  rise  to  balanitis,  but  by  far  the  most  common 
source  of  irritation  is  one  which  is  caused  by  the  reten- 
tion and  decomposition  of  the  smegma  secretion  behind 
a  tight  foreskin.  There  are  manv  other  forms  of  irrita- 
tion, such  as  a  soft  sore,  a  hard  chancre,  epithelioma, 
herpes,  and  eczema,  which  also  ma}-  give  rise  to  balanitis, 
but  in  almost  all  these  cases  there  will  also  be  found  an 

99  7—2 


loo     Treatment  of  Gonorrhoea  in  the  Male 

accumulation  of  smegma  beneath  a  lont,'  and  tij^ht  fore- 
skin. riiL'  occurrence  of  balanitis  in  connection  with 
gonorrhtca  is  to  be  attributed  to  the  additional  irritation 
produced  by  the  urethral  discharge  retained  and  decom- 
posing behind  a  long  prepuce.  It  is  certainly  seldom  that 
the  gonococcus  directly  causes  the  balanitis. 

Symptoms. — The  inflammation  of  the  glans  produces 
an  itching  and  soreness  of  the  end  of  the  penis,  which 
becomes  red,  swollen,  and  (edematous,  and  from  beneath 
the  foreskin  a  free  and  intensely  foetid  discharge  e.xudes. 
If  the  prepuce  be  withdrawn,  the  mucous  membrane 
lining  it  and  covering  the  glans  will  be  found  to  be  in- 
flamed and  often  ulcerated  in  places.  The  inflammation 
ma}' become  so  intense  as  to  cause  gangrene  of  the  tissues. 
This  is  generally  limited  to  the  prepuce,  but  may  involve 
a  considerable  portion  of  the  integument  of  the  penis. 

There  is  alwa\-s  a  certain  amount  of  phimosis  present, 
and,  should  repeated  attacks  of  balanitis  occur,  the  pre- 
pucial  opening  is  likely  to  become  so  thickened  and  con- 
tracted as  to  render  it  difficult  or  impossible  to  uncover 
the  glans.  Should  such  a  phimotic  foreskin  be  forcibly 
retracted  over  the  glans,  the  condition  known  as  para- 
phimosis results.  The  constricted  orifice  of  the  prepuce 
tightly  encircles  the  glans,  and  obstructs  the  return'of  the 
blood  by  the  veins.  This  causes  the  end  of  the  penis  to 
swell,  and  the  mucous  membrane  of  the  foreskin  which 
lies  in  front  of  the  constricting  ring  becomes  greatly  dis- 
tended with  serous  e.xudation,  and  ma},  if  unrelieved, 
become  gangrenous. 

Diagrnosis. — The  diagnosis  of  balanitis  rarely  presents 
an}'  difficulty,  save  where  marked  phimosis  prevents  the 
inspsction  of  the  meatus  and  glans. 

A  small  quantit}'  of  the  pus  e,\uding  from  under  the 
prepuce  should  be  smeared  on  a  glass  slide,  and  examined 


Minor  Complications  '•''" 

microscopically  for  tlie  iircsence  or  absence  of  the  j^'f^no- 
coccus.  The  prepucial  sac  shonlfl  then  be  thorouglily 
cleansed  by  irrigation  with  a  dilute  antiseptic  solution. 
The  patient  is  then  allowed  to  pass  water  into  a  glass, 
when,  if  the  urine  is  turbid,  it  shows  that  urethritis  is 
present  as  well  as  balanitis.  Whether  the  gonococcus  be 
present  or  not,  the  glans  should  be  carefully  examined  for 
soft  sores  or  syphilitic  chancre. 

Treatment.  —  The  prepucial  sac  should  be  gently 
cleansed  from  all  secretion  with  warm  water,  and  then 
irrigated  with  a  mild  astringent  antiseptic  solution,  such 
as  nitrate  of  silver  (i  in  5,000).  This  should  be  repeated 
several  times  a  day.  If  the  foreskin  can  be  withdrawn, 
a  thin  layer  of  gauze  soaked  in  the  lotion  should  be  inter- 
posed between  the  glans  and  the  prepuce.  Later,  when 
the  secretion  is  lessened,  the  lotion  may  be  replaced  by 
an  astringent  dusting-powder,  such  as  oxide  of  zinc. 
When  the  phimosis  prevents  the  glans  being  uncovered, 
the  parts  must  be  cleansed  and  irrigated  by  means  of  a 
wound  syringe,  the  nozzle  of  which  is  inserted  under  the 
prepuce.  Where  there  is  much  oedema  and  cellulitis 
present,  evaporating  lotions  and  wet  dressings  may  be 
applied  to  the  penis.  In  cases  of  severe  cellulitis,  where 
gangrene  threatens,  the  prepuce  should  be  circumcised  or 
divided  by  a  free  dorsal  incision. 

Para-urethral  Canals. 

A  careful  examination  of  the  penis,  more  especially 
in  the  neighbourhood  of  the  frenum  and  meatus,  will 
frequently  detect  one  or  more  fine  blind  canals  or  diver- 
ticula of  from  i  to  I  inch  in  length,  and  just  wide  enough 
to  admit  a  fine  probe.  These  canals  are  lined  by  squamous 
epithelium,  and  may  be  regarded  as  fine  invaginations  of 
the  skin.     They  are  of  interest  from  the  fact  that  occa- 


I02     Treatment  of  Gonorrhoea  in  the  Male 

sionally  they  become  inoculatiel  with  t^onorrhcea,  and 
may  Fetain  the  infection  long  after  the  urethritis  is  healed, 
or,  by  closure  of  the  mouth  of  the  canal,  may  give  rise  to 
a  small  abscess. 

Treatment.  —  Should  the  injection  of  tiie  canal  with 
nitrate  of  silver  solution  prove  insufhcient  to  cure  the 
inflammation,  the  canal  should  be  destroyed  by  means 
of  a  fine  galvano-cautery  point :  or  it  may  be  laid  open 
b_\'  means  of  an  incision,  and  the  wound  allowed  to  heal 
b}-  granulation. 

Internal  Para-urethral  Canals. 

Less  common,  though  more  important,  are  similar 
canals  which  open  into  the  lumen  of  the  urethra  near  the 
meatus.  Obviously,  such  canals  are  peculiarly  liable  to 
become  the  focus  of  a  chronic  urethritis,  and  from  their 
situation  are  likely  to  be  overlooked.  Their  detection  and 
treatment  require  the  use  of  the  urethroscope. 

Papillomata. 

It  frequentl}-  happens  that  numerous  small  warts 
develop  on  the  mucous  membrane  and  skin  of  the  genitals 
of  persons  suffering  from  gonorrhoea.  These  warts  are 
true  papillomata,  and  develop  in  consequence  of  the 
irritation  which  decomposing  pus,  more  especially  gonor- 
rhceal  pus,  produces  on  the  skin  and  mucous  membrane, 
which  is  constantly  bathed  by  it. 

These  warts  most  frequently  grow  from  the  mucous 
membrane  covering  the  glans  penis,  more  especially  about 
the  corona,  but  they  are  also  found  on  the  integument  of 
the  penis,  the  scrotum,  the  anal  region,  and  the  inner  part 
of  the  thighs,  and  occasionally  within  the  urethral  canal. 

In  the  female  the}-  are  met  with  springing  from  the 
mucous  and  cutaneous  surface  of  the  vulva  and  perinaeum. 


Minor  Complications  lo.'^ 

The  warts  may  be  single,  but  usually  arc  multiple,  and 
vary  in  si;;e  from  that  of  a  pin's  head  tfj  large  caulillower- 
like  growths.  Their  appearance  and  consistency  differ 
considerably,  according  to  their  situation.  If  growing 
from  the  mucous  membrane,  where  they  are  kej)t  moist, 
the  epithelium  covering  them  is  thin  and  delicate,  so  that 
they  readily  bleed  on  being  touched.  In  other  drier 
situations  they  become  covered  with  a  hard  and  horny 
epithelium. 

Histologically  these  growths  are  true  papillomata.  The 
papillae  of  the  integument  are  greatly  hypertrophied  and 
oedematous,  and  are  covered  by  a  thickened  layer  of  epi- 
thelium. They  therefore  in  no  way  structurally  resemble 
the  small-celled  infiltration  of  the  syphilitic  condylomata, 
with  which  they  are  sometimes  confounded. 

Apart  from  the  fact  that  they  grow  in  situations  where 
the  integument  is  exposed  to  the  irritating  and  macerating 
action  of  foetid  discharges,  it  is  not  known  what  gives  rise 
to  them.  It  has  been  supposed  that  the  growth  is  the 
result  of  a  specific  micro-organism,  but  the  proof  of  such 
an  assumption  is  wanting.* 

Treatment. — There  is  seldom  any  difficulty  in  effec- 
tually dealing  with  this  condition.  The  irritating  dis- 
charge must  be  treated  and  the  affected  part  kept 
scrupulously  clean.  In  many  cases  this  is  all  that  is 
necessary  to  cause  the  warts  to  shrivel  up  and  disappear. 
If  they  persist  they  may  be  touched  occasionally  with  a 
strong  alcoholic  solution  of  perchloride  of  mercury,  and 
kept  dusted  with  an  astringent  powder,  such  as  alum, 
oxide  of  zinc,  or  resorcin.  Larger  growths  are  best 
removed  with  the  knife  or  scissors,  and  the  base  should 
be  touched  with  the  cautery  to  arrest  the  hamiorrhage. 
*  Unkovsky,  WratscJi,  Nos.  14  and  46,  1S85. 


I04     Treatment  of  Gonorrhoea  in  the  Male 

Peri-urethral   Inflammation    and   Abscess    (Folliculitis 
Urethralis). 

In  speaking  of  the  pathology  of  chronic  uivthritis, 
attention  has  been  drawn  to  the  frcquenc\  with  which  the 
small  glands  and  crypts  of  Littre  and  Morgagni  become 
the  foci  of  gonorrhceal  inflammation.  At  times,  through 
the  blocking  of  the  duct  of  the  gland,  or  from  other 
causes,  the  gonococci  invade  the  periglandular  tissue,  and 
give  rise  to  an  inflammation  outside  the  urethra,  in  the 
cavernous  tissue  (peri-urethal  inhltration),  which  is  apt  to 
develop  into  a  small  abscess.  As  a  rule,  such  infiltrations 
and  abscesses  are  quite  small — from  the  size  of  a  millet- 
seed  to  a  pea — and  are  situated  about  the  floor  of  the 
penile  urethra.  Occasionally  the  infiltration  is  much 
larger,  so  that  a  considerable  portion  of  the  corpus 
spongiosum  or  cavernosum  is  in\ol\ed.  Should  such  an 
infiltration  resolve,  it  leaves  a  fibrous  induration  or 
sclerosis,  the  subsequent  contraction  of  which  may  give 
rise  to  considerable  distortion  of  the  penis.  On  the  other 
hand,  the  infiltration  may  proceed  to  the  formation  of  an 
abscess,  which  may  either  burst  into  the  urethra  or  the 
under  surface  of  the  penis.  In  the  latter  case  a  trouble- 
some urinary  fistula  may  be  caused. 

Symptoms. — The  small  infiltrations  and  abscesses  fre- 
quentl}-  give  rise  to  no  special  subjective  symptoms,  beyond 
a  slight  local  pain  on  micturition  or  erection.  Careful 
palpation  of  the  penis  may  detect  one  or  more  tender 
spots,  generally  below  or  to  one  side  of  the  urethra. 
Pressure  over  the  tender  spot  may  express  a  bead  or  two 
of  pus,  which  appears  at  the  meatus.  The  presence  of  a 
large  induration  in  the  corpus  cavernosum,  or  spongiosum, 
produces  a  considerable  distortion  of  the  penis,  especially 
on  erection,  the  organ  being  curved  towards  the  affected 


Minor  Complications  105 

part.  In  the  early  stages  of  the  inllnrninatory  iiililt  i;it  ion 
into  these  tissues  an  erection  is  accompanied  l:)y  chordee 
venerea,  causing  severe  pain.  Later,  when  the  infiltration 
has  become  indurated,  nr;  pain  is  felt,  but  the  distortion  of 
the  penis  may  prove  an  obstacle  to  coitus. 

Treatment. — As  soon  as  a  periurethral  infiltration  is 
detected,  all  local  urethral  treatment  should  be  suspended, 
or,  at  any  rate,  reduced  to  a  minimum.  For  the  preven- 
tion of  the  painful  chordee  chief  reliance  is  to  be  placed 
on  free  purging,  light  diet,  and  rest  in  bed.  Cold-water 
dressings  may  be  applied  locally,  and  full  doses  of  bromide 
of  potassium  given  by  the  mouth.  Later,  in  order  to  assist 
the  absorption  of  the  infiltration,  the  indurated  area  may 
be  rubbed  with  iodine  vasogen  or  mercurial  ointment. 
Should  an  abscess  form  subcutaneously,  it  should  be  early 
incised. 

Inflammation  of  Cowper's  Gland. 

Occasionally  the  small  glands  of  Cowper,  which  are 
situated  in  the  perinasum  on  either  side  of  the  urethra, 
become  inflamed.  When  this  happens  a  firm,  painful 
swelling,  about  the  size  of  a  pigeon's  egg,  forms  in  the 
peringeum,  midway  between  the  scrotum  and  anus.  Should 
the  inflammation  proceed  to  the  formation  of  an  abscess, 
the  swelling  increases  in  size  until  it  impedes,  more  or 
less,  the  passage  of  urine  and  renders  defaecation  painful. 
The  skin  over  it  becomes  red  and  acutely  tender.  If 
unrelieved,  the  abscess  generally  bursts  externally,  but 
may  do  so  into  the  urethra,  or,  more  rarely,  into  the 
rectum.  The  treatment  consists  in  the  application  of  hot 
fomentations  to  the  perinasum,  to  relieve  the  pain  in  the 
early  stages,  and  the  free  opening  of  the  abscess  from  the 
perineum  as  soon  as  pus  is  detected.  It  is  undesirable 
to  dela}^  the  opening  of  these  abscesses,  as  otherwise  they 


Id     Treatment  of  Gonorrhoea   in  the  Male 

ina\-  burst    into   the   urethra  or  rectum,  and  gi\e  rise  to 
troublesome  sinuses. 

Lymphangitis  and  Lymphadenitis. 

In  ahnost  every  case  of  acute  ^onorrhcea  where  the 
symptoms  are  at  all  severe  the  inj^uinal  hniphatic  glands 
will  be  found  to  be  slightly  swollen  and  tender.  Generally 
this  lymphadenitis  soon  subsides,  and  hardly  calls  for 
special  treatment.  More  rarely  the  inflammation  is  of  a 
severer  type,  causing  considerable  distress,  and  proceeding 
eventually  to  the  formation  of  one  or  more  abscesses  or 
buboes.  This  lymphadenitis  may  or  may  not  be  accom- 
panied by  an  inflammation  of  the  cutaneous  lymphatic 
vessels  (lymphangitis)  of  the  penis.  When  such  is  the  case, 
faint,  thin,  red  lines  are  seen  in  the  skin  of  the  penis,  run- 
ning from  the  glans  towards  the  pubes.  If  the  penis  be 
palpated,  these  inflamed  lymphatic  vessels  can  be  felt  as 
firm  cords,  about  the  size  of  a  steel  knitting-needle.  The 
presence  of  these  inflamed  lymphatics  may  give  rise  to 
various  distortions  of  the  penis,  as  in  chordee. 

Treatment. — Rest  and  the  application  of  evaporating 
lotions,  or  glycerine  and  belladonna,  to  the  inflamed  parts 
is,  as  a  rule,  all  that  is  called  for  in  these  cases.  Should 
an  abscess  form,  an  incision  to  evacuate  the  pus  is 
indicated. 


CHAPTER  II 

EPIDIDYMITIS 

Next  to  prostatitis,  the  most  frequent  complication  of 
posterior  urethritis  is  an  inflammation  of  the  epididymis. 
This  compHcation  occurs  in  from  to  to  30  per  cent,  of  all 
cases  of  urethritis.  It  is  found,  as  we  might  expect,  far 
more  commonly  in  hospital  practice  than  privately.  There 
can  now  be  little  doubt  that  epididymitis  is  due  to  a  direct 
extension  of  the  gonococcal  inflammation  of  the  posterior 
urethra  by  means  of  the  vas  deferens.  In  the  majority  of 
cases  this  infection  would  seem  to  be  a  pure  gonococcal 
one,  though  it  may  be  a  mixed  infection.  The  exciting 
cause  of  this  disorder  is  to  be  sought  for  in  anything  which 
may  give  rise  to  an  exacerbation  of  the  urethritis,  and  so 
further  its  extension  to  the  posterior  portion  of  the  urethra. 
Violent  bodily  exercise,  excessc  in  Baccho  et  venere,  in- 
strumental examination  or  irritating  injections  are  all  apt 
to  be  followed  by  the  sudden  development  of  epididy- 
mitis. Not  infrequently  the  treatment  of  the  urethritis, 
more  especially  the  injections,  is  blamed  as  giving  rise  to 
the  epididymitis.  That  this  is  often  unjust  was  shown  by 
Le  Fort,  who  demonstrated  that  it  was  in  the  untreated 
cases  of  urethritis  that  this  complication  was  most  common. 
Out  of  576  cases  of  epididymitis,  264  had  been  un- 
treated, 73  treated  by  balsams,  82  treated  by  injections. 

107 


loS     Treatment  of  Gonorrhoea  in  the  Male 

60  treated  by  balsams  and  injections,  and  in  97  the  treat- 
ment was  unknown. 

Epididymitis  most  commonly  develops  during  the  third 
or  fourth  week  of  a  urethritis,  that  being  the  most  usual 
time  for  posterior  urethritis  to  appear;  but  it  may  occur 
at  any  period,  from  the  earliest  onset  of  the  acute  disorder 
to  late  in  the  chronic  condition.  It  attacks  either  gland 
with  almost  equal  frequency.  In  a  small  percentage  of 
cases  (5  per  cent.,  Castehiau)  both  gland=  may  be  affected 
simultaneousK'. 

Symptoms. — The  inflammation  generally  begins  sud- 
denly. The  patient  experiences  pain,  without  any 
warning,  in  one  of  the  testicles,  which  he  finds  to  be 
swollen  and  acutely  tender.  Both  the  swelling  and  the 
pain  rapidly  increase.  The  inflammation  is  principally 
confined  to  the  epididymis,  more  especially  the  globus 
major,  but  the  gland  proper  also  suffers  to  a  greater  or  less 
degree.  A  serous  or  sero-purulent  fluid,  in  which  gonococci 
may  often  be  detected,  distends  the  tunica  vaginalis.  If 
the  inflammation  is  severe,  the  scrotal  integuments  become 
thickened  and  cedematous,  the  small  folds  obliterated,  and 
the  surface  red  and  glistening.  There  is  usually  some 
amount  of  fever  present,  and  a  feeling  of  nausea  and  even 
vomiting  may  be  caused  by  the  severity  of  the  pain.  This 
is  the  most  severe  when  the  spermatic  cord  is  also  involved 
in  the  inflammation  (funiculitis).  In  such  cases  the 
whole  cord  is  swollen,  firm,  and  acutely  tender.  More 
rarely  the  vas  deferens  alone  is  involved,  the  other  con- 
stituents escaping.  The  acute  attack  reaches  its  height  in 
from  four  to  five  days,  and  then  soon  begins  to  decline. 
The  effusion  into  the  tunica  vaginalis  becomes  absorbed, 
and  so  considerably  reduces  the  size  of  the  scrotal  swelling. 
The  swollen  gland  and  epididymis  slowly  resume  their 
natural  size,  though   many  weeks,  or  even  months,  may 


Epididymitis  109 

pass  bcfcjrc  tliis  is  completely  (;ITc(:t(;(l.  /\ltlioii;'.li  ;il>soliit(; 
restitution  may  take  place,  as  a  rule  one  or  more  small 
indurated  nodules  in  the  epididymis  permanently  persist. 
During  the  acute  stage  of  the  disease  the  urethral  secretion 
greatly  diminishes,  so  that  the  patient  no  longer  notices 
its  presence.  This  fact,  though  well  known,  is  a  constant 
trap  to  the  medical  student,  who  diagnoses  traumatic 
orchitis  because  the  urethra  is  free  from  discharge.  As 
the  acuteness  of  the  epididymitis  subsides,  the  urethral 
secretion  reappears.  Although  epididymitis  generally 
develops  in  an  acute  manner,  occasionally  it  is  the  very 
reverse,  and  the  whole  course  of  the  disease  may  be  so 
mild  as  barely  to  attract  the  notice  of  the  patient  to  this 
complication.  The  inflammation,  like  most  gonorrhceal 
troubles,  is  liable  to  severe  relapses  at  any  period,  and  it 
may  happen  that  just  as  one  gland  is  recovering  the  other 
is  attacked. 

Diag'nosis. — -It  is  but  rarely  that  any  difficulty  is  ex- 
perienced in  making  the  diagnosis  of  gonorrhceal  epididy- 
mitis. The  acuteness  of  the  early  symptoms  distin- 
guishes it  from  syphilitic  and  tubercular  orchitis.  More- 
over, apart  from  the  history  of  the  case,  and  the 
presence  of  syphilitic  or  tubercular  lesions  elsewhere,  the 
character  of  the  swelling  is  different ;  for  the  enlarge- 
ment of  the  gland  and  epididymis  in  urethritis  is  of  a 
smooth  and  uniform  nature,  whilst  the  tubercular  affection 
is  generally  limited  to  the  epididymis,  and  is  nodular  in 
character.  Syphilis  usually  attacks  the  organ  proper,  and 
is  seldom  confined  to  the  epididymis.  Perhaps  the  most 
frequent  mistake  made  in  diagnosis  is  the  result  of 
accepting  naively  the  patient's  statement  that  the  swelling 
is  due  to  a  knock  or  strain.  All  doubt  as  to  the  origin  of 
the  inflammation  is  generally  settled  at  once  by  directing 
the  patient  to  make  water,   preferabl}^  into  two  glasses. 


iio     Treatment  of  Gonorrhoea  in  the  Male 

when  the  presence  of  pus,  threads,  or  mucus  in  the  urine 
will  at  once  proclaim  its  true  nature.  An  acute  epididy- 
mitis in  an  undescended  gland  may  lead  to  a  diagnosis 
of  strantj^ulated  inj^uinal  hernia  or  acute  adenitis. 

Prognosis. — Apart  from  rare  instances  wlure  the  acute 
inflammation  has  spread  to  the  peritoneum  or  has  given 
rise  to  intra-abdominal  abscess,  the  prognosis  as  regards 
life  is  certainly  good,  l^ut  it  is  far  graver  when  we  regard 
the  functional  acti\ity  of  the  gland.  Attention  has  been 
drawn  to  the  frequency  with  which  an  indurated  nodule 
or  sclerosed  area  persistently  remains  as  the  result  of  the 
acute  inflammation.  Such  an  induration,  especially  if 
situated  in  the  globus  minor,  is  very  apt  to  reduce  or 
occlude  the  lumen  of  the  seminal  canal,  and  so  hinder  the 
passage  of  the  seminal  fluid,  thus  leading  to  oligospermia, 
if  not  azoospermia.  The  danger  of  such  after-troubles  is 
naturally  vcr}'  much  greater  in  cases  of  double  epididy- 
mitis, though  sterility  does  not  necessarily  follow  even 
here.  According  to  Benzler,  the  total  sterility  (complete 
sterility  and  one  child  sterility  taken  together)  in  cases  of 
single  epididymitis  =  36'g  per  cent.,  and  that  of  double 
epididymitis  ==  63*5  per  cent. 

Treatment.  —  A  point  of  primary  importance  to  be 
observed  on  the  onset  of  epididymitis  is  that  all  local 
treatment  of  the  urethritis  be  at  once  suspended.  Whilst 
this  complication  is  in  its  acute  stage  all  injections  or 
other  topical  applications  will  only  aggravate  the  trouble. 
Even  when  the  pain  has  gone  and  the  swelling  is  dis- 
appearing it  is  a  grave  mistake  to  be  in  a  hurry  to  recom- 
mence the  local  treatment.  During  the  acute  stages  we 
must  rely  upon  the  internal  administration  of  the  balsams, 
or,  better,  salicylate  of  soda,  in  order  favourably  to  influence 
the  urethral  inflammation.  As  regards  the  treatment  of 
the  epidid}mitis   itself,  our  task   is  first  of  all  to  relieve 


Epididymitis  '  '  ' 

the  severe  pain,  and  then  to  assist  tiie  absorption  of  tlx- 
inflammatory  prodncts  as  speedily  and  ;is  completely  as 
possible.  Whenever  practicable,  the  patient  slirjulr]  Ijc 
kept  in  bed,  for  it  is  only  thus  that  the  parts  can  be 
adequately  rested.  '  Rest  in  bed  '  is  certainly  the  most 
valuable  advice  we  can  give  to  our  patient,  and  neglect 
of  it  often  leads  to  dire  pains  and  penalties. 

If  the  patient  is  unable  to  remain  in  bed,  the  testicles 
should  be  raised  and  supported  by  the  application  of  a 
suitable  suspensory  bandage.  There  is  no  lack  of  such 
bandages  on  the  market,  but  the  majority  of  them  are 
useless  for  this  purpose.  The  bandage  must  be  so  con- 
structed as  not  only  to  allow  the  testicles  to  be  raised, 
but  also  to  be  drawn  up  against  the  body.  The  purse  of 
the  bandage  must  be  large  enough  to  take  a  thick  padding 
of  wool,  and  must  be  so  adjustable  as  to  permit  of  a 
proper  degree  of  pressure.  A  thoroughly  serviceable  one 
is  that  devised  by  Neisser  (see  Fig.  34),  but  a  fairly 
efficient  one  can  be  readily  fashioned  out  of  a  common 
triangular  bandage. 

In  the  earliest  stages  of  this  complication  the  pain  is 
perhaps  best  relieved  by  the  application  of  cold  to  the  part. 
The  scrotum  and  groin  are  enveloped  in  absorbent  gauze, 
which  is  kept  moist  bj'  some  simple  evaporating  lotion. 
This  can  onl}-  be  done  efficiently  when  the  patient  is 
lying  in  bed,  with  the  scrotum  supported  by  a  small 
cushion  placed  between  the  thighs.  In  the  later  stages, 
and  always  if  the  patient  is  getting  about,  the  pain  is 
better  relieved  b}^  warm  anodyne  applications. 

Of  these  I  do  not  think  there  is  an}"  better  than  the 
glycerine  and  belladonna  of  the  English  Pharmacopceia 
applied  in  the  following  way :  The  groin  and  scrotum  on 
the  affected  side  are  thickly  smeared  with  the  preparation, 
and  then  covered  with  a  fold  of  absorbent  gauze,  which 


1 1  2     Treatment  of  Gonorrhoea  in  the  Male 


has  been  wrung  out  of  hot  water.  0\'er  this  is  laid  a 
piece  of  gutta-porcha  tissue,  and  then  a  thick  hiyer  of 
waddinsT.  The  whole  dressing  is  retained  in  its  place,  and 
the  testicle  elevated  and  gentl}-  pressed  against  the  body 
by  a  well-htting  suspensory  bandage  (Fig.  34).  A  more 
cleanly  application  is  that  of  antiphlogistine  (a  patent 
mixture    o['   infusorial    earth,  glycerine,  and    antiseptics), 


Fig.   34. — Suspensory  Bandage. 

which  I  have  found  con\-enient  and  efficacious.  When 
the  pain  is  exceedingly  severe  it  may  be  relieved  b}-  the 
administration  of  morphia. 

Under  the  above  treatment  the  acute  symptoms 
generally  abate  within  a  few  days.  The  pain  and  dis- 
comfort disappear,  and  the  swelling  gradually  subsides. 
The  absorption  of  the  inflammatory  products  is  materially 
hastened  by  gentle  pressure  applied  to  the  part.  At  first 
this  is  best  done  by  means  of  the  suspensory  bandage, 
but  later,  when  all  tenderness  has  disappeared  and  the 
swelling    is    limited    to    the    epididymis,    it    is   generally 


Epididymitis  1 1  ^ 

advised  to  apply  the  pressure  b}'  means  of  firm  straj^ping. 
It  is,  however,  far  from  easy  to  straj)  a  testicle  so  as  to 
obtain  the  right  degree  of  pressure,  and  a  well-applied 
bandage  is  quite  as  efficacious  and  much  more  agreeable 
to  the  patient. 

In  addition  to  the  application  of  pressure  to  the  testicle, 
iodide  of  potassium  may  be  given  internally,  and  applied 
locally  in  the  form  of  an  ointment,  with  a  view  to  aid  the 
absorption  of  the  infiltration.  On  those  rare  occasions 
where  an  abscess  forms  in  the  epididymis  it  must  be  treated 
on  general  surgical  lines,  viz.,  opened  freely,  and  packed 
with  gauze  until  completely  healed. 

Lastly,  it  must  be  remembered  that  the  posterior 
urethritis  which  gave  rise  to  the  epididymitis  will  require 
appropriate  treatment. 


chapti:r  III 

PROSTATITIS 
Acute  Prostatitis 

When  in  the  course  of  an  acute  gonorrhcea  the 
inflammation  spreads  to  the  posterior  urethra  (as  it  does 
usually  about  the  end  of  the  third  week),  it  almost  of 
necessity  involves  the  prostatic  gland,  giving  rise  to  a 
purulent  catarrh  of  its  numerous  mucous  follicles.  This 
acute  follicular  or  catarrhal  prostatitis  is  limited  to  the 
mucous  membrane,  and  gives  rise  to  no  s\-mptoms 
beyond  those  of  acute  posterior  urethritis,  already 
described.  Usually,  under  appropriate  treatment,  the 
inflammation  readily  subsides  ;  but  occasionalh',  in 
consequence,  perhaps,  of  some  indiscretion  of  diet  or 
hygiene,  the  inflammatory  action  spreads  to  the  inter- 
stitial substance  of  the  prostate,  and  so  gives  rise  to  an 
acute  diffuse  or  parench}-matous  prostatitis. 

Here  the  inflammation  spreads  from  the  mucous  mem- 
brane deep  into  the  substance  of  the  prostate,  and  there, 
between  the  glandular  elements,  forms  numerous  small 
yellow  infiltration  foci,  which  either  develop  into  minute 
miliary  abscesses  or  coalesce  so  as  to  form  one  large 
collection  of  pus.  In  specially  severe  cases  the  inflam- 
mation may  spread  to  the  periprostatic  cellular  tissue, 
forming  a  diffuse  pehic  phlegmon  of  a  most  serious 
character.     The  symptoms  evoked  by  an  acute  parenchy- 

114 


Prostatitis  1 1 5 

matoiis  prostatitis  vary  according'  to  the  scat  and  sevorit}' 
of  the  inflammatory  process.  As  n  rule  the  onset  is 
decidedly  sudden,  the  patient  experiencing  a  feeling  of 
weight  and  uneasiness  about  the  rectum  and  perinteum, 
as  though  there  were  a  foreign  body  in  the  bowel ;  the 
desire  for  micturition  becomes  distressingly  frequent, 
though  the  urine  is  passed  with  increasing  difficulty  and 
pain  ;  retention  of  urine  is  not  uncommon.  The  tempera- 
ture rises  rapidly,  and  general  feverish  symptoms  are 
present.  Per  rectum  the  prostate  can  be  felt  to  be 
greatly  swollen,  hot,  and  acutely  tender.  Under  appro- 
priate treatment  the  inflammation  usually  resolves,  but 
occasionally  proceeds  to  suppuration,  and  the  abscess,  if 
untreated,  after  a  longer  or  shorter  time,  bursts  into  the 
urethra  or  rectum,  or,  rarely,  opens  externally  through 
the  perinseum. 

In  the  phlegmonous  form  all  these  symptoms  are 
greatly  exaggerated.  The  temperature  is  high  and  often 
accompanied  by  severe  rigors.  On  examination  per  rectum 
the  outline  of  the  prostate  is  not  readily  felt,  on  account 
of  a  diffuse  boggy  or  fluctuating  swelling  occupying  the 
anterior  wall  of  the  rectum. 

As  soon  as  this  complication  is  suspected  all  local  treat- 
ment of  the  urethritis  must  be  suspended ;  the  patient 
must  be  kept  in  bed,  on  a  low  diet,  and  the  congestion  of 
the  lower  part  of  the  bowel  relieved  by  a  mild  purgative. 
For  the  relief  of  the  pain  and  tenesmus  heat  should  be 
applied  to  the  perina;um  by  means  of  large  poultices 
or  frequent  sitz-baths,  or  hot-water  enemata  may  be  given. 
For  severe  pain  belladonna  or  morphia  suppositories  are 
valuable.  If  the  urinary  retention  persists  in  spite  of 
morphia  and  hot  applications,  the  water  must  be  drawn 
off  with  a  soft  rubber  catheter.  As  soon  as  an  abscess 
is  detected  it  should  be  opened,  the  incision  being  made 

8—2 


1 1 6     Treatment  of  Gonorrhoea  in  the  Male 

through  the  perincLUin  by  choice,  but  iu  the  rectum  if  the 
abscess  should  point  there. 

Before  incising  such  an  abscess  through  the  rectum  it 
is  advisable  to  irrigate  the  lower  part  of  the  bowel  with  a 
I  per  cent,  protargol  solution,  with  a  view  to  preventing  a 
possible  gonorrhoeal  infection  of  the  rectum. 

Chronic  Prostatitis. 

It  is  necessary  now  to  draw  attention  to  this  frequent, 
though  rarely  recognised,  complication,  a  condition  which 
has,  perhaps,  more  influence  in  keeping  up  the  chronic 
urethritis  than  any  yet  discussed.  Chronic  prostatitis 
generally  develops  insidiously  during  the  course  of  a 
chronic  urethritis,  less  frequently  as  the  continuation 
of  an  acute  prostatitis.  It  arises  as  one  of  the  conse- 
quences of  the  gonorrhcea  spreading  to  the  posterior 
urethra  and  infecting  the  prostatic  glands.  A  chronic 
desquamative  catarrh  of  these  glands  is  set  up,  which  has 
little  or  no  tendency  either  to  spread  to  the  parenchyma 
of  the  prostate  or  to  the  formation  of  an  abscess. 

As  this  condition  evokes  no  very  characteristic  symp- 
toms, its  existence  has  not  received  wide  recognition  ; 
consequently,  there  are  few  statistics  from  which  a  definite 
statement  as  to  its  relative  frequency  can  be  determined. 
Still,  there  is  already  sufficient  evidence  to  show  that 
chronic  prostatitis  is  an  exceedingly  common  complica- 
tion of  chronic  urethritis.  Indeed,  it  will  not  be  over- 
stating the  case  to  affirm  that  it  is  more  commonly 
present  than  absent  in  all  cases  of  urethritis  of  more  than 
three  months'  duration.* 

*  In  a  hundred  cases  of  chronic  urethritis  examined  by  Casper,  the 
prostate  was  found  to  be  inflamed  in  85  per  cent.  ('  Monatsberichte 
iiber    Ham    und    Sexual-apparates,'    1900).      M.    \'.    Zeissl   {Wic/ier 


Prostatitis  i  '  7 

The  ini])ortrince  of  this  disf.TLSC  lies  not  so  much  in  the 
symptoms  it  creates  as  in  the  difliculty  with  which  it  is 
eradicated.  Long  after  the  gonococci  have  disappeared 
from  the  urethral  secretion  they  can  frequently  be  found 
in  the  expressed  prostatic  secretion.  And  so  long  as  a 
focus  of  gonorrhceal  inliammation  persists  in  the  prostate, 
the  patient  is  naturally  liable  to  a  recurrence  of  the 
urethritis.  Hence  the  importance  of  examining  the 
prostatic  secretion  before  dismissing  the  patient  as 
definitely  cured. 

Symptoms.  — Chronic  catarrhal  prostatitis  gives  rise  to 
no  very  characteristic  subjective  symptoms.  The  diag- 
nosis rests  almost  solely  upon  the  microscopical  examina- 
tion of  the  secretion.  The  patient  usually  presents  the 
ordinary  symptoms  of  chronic  posterior  urethritis  —  a 
slightly  increased  frequency  of  micturition,  and  some 
sexual  irritability  or  disturbance,  a  feeling  of  weight  and 
oppression  about  the  neck  of  the  bladder,  and  threads 
may  be  traced  in  the  second  portion  of  the  urine.  Often 
the  most  marked  symptom  is  a  grave  disturbance  of  the 
general  nervous  system.  The  patient  becomes  very  hypo- 
chondriacal, and  highl}-  exaggerates  his  symptoms  and  the 
severity  of  his  complaint,  and  he  is  very  apt  to  develop 
into  a  chronic  sexual  neurasthenic. 

All  subjective  symptoms  may,  however,  be,  and  fre- 
quently are,  entirely  absent ;  and  it  is  not  until  the  pros- 
tatic secretion  is  examined  that  the  disease  is  recognised. 
For  the  purpose  of  microscopical  examination  the  pros- 
tatic fluid  is  best  obtained  by  first  instructing  the  patient 
to  pass  water,  so  as  thoroughly  to  clear  the  urethra  from 
its  secretion,  then,  while  the  patient  kneels  on  a  couch, 

Klinik,  1902)  is  of  opinion  that  prostatitis  is  almost  an  invariable 
accompaniment  of  a  protracted  gonorrhoea.  See  also  Posner,  Seventh 
Congress  fiir  innere  jNIedicin.  18S9. 


iiS     Treatment  of  Gonorrhoea  in  the  Male 

gently  stroking  the  prostate  from  behind  forwards  by 
means  of  Feleki's  instrument,  or  better,  by  the  index 
finger  of  the  surgeon,  protected  by  a  rubber  glove.  The 
prostatic  fluid  pressed  from  the  gland  passes  down  the 
urethra,  and  is  collected  at  the  meatus  in  a  watch-glass. 
Other  methods  of  obtaining  the  secretion  have  already 
been  described  (see  p.  78). 

The  normal  prostatic  secretion  is  a  thin,  milky  fluid  of 
a   faintly   acid   reaction,    and    having    the    characteristic 


Fig.  35. — Sperm  Crystals. 

spermatic  odour.  Under  the  microscope  the  fluid  is  seen 
to  consist  principally  of  numerous  small,  highly  refractive 
lecithin  bodies,  with  some  polygonal  and  cylindrical 
epithelial  cells,  and  here  and  there  a  laminated  amyloid 
body.  A  characteristic  feature  of  the  prostatic  fluid  is  the 
presence  of  long  needle  or  whetstone  shaped  crystals,  the 
so-called  sperm  crystals  of  Bottcher  or  Charcot  (Fig.  35). 
In  order  to  demonstrate  these  crystals  the  prostatic  fluid 
must  be  obtained  free  from  any  admi.xture  of  urine.  A  drop 
of  the  secretion  is  mixed  with  a  drop  of  i  per  cent,  solution 
of  phosphate  of  ammonia,  then  slowh'  dried  under  the 
protection  of  a  cover-glass.     After  some  little   time   the 


Prostatitis  1 1  ^) 

crystals  may  be  seen  in  lar^^r:  iiiiinhcrs.  ShonKI  tlic 
prostate  be  inflamed,  in  addition  to  thcj  nrjrmal  celhilar 
bodies,  there  will  be  seen  pus  cells  in  large  and  over- 
whelming numbers,  and  perhaps  micro-organisms  will  be 
present  also.  The  frequency  with  which  gonococci  are 
found  in  the  secretion  of  chronic  prostatitis  is  variously 
stated  by  different  authorities.  Neisser  believes  that  the 
gonococcus  is  almost  always  present;  Cohn  and  Wossildo, 
on  the  other  hand,  hold  the  opposite  opinion.  Personally, 
I  have  only  found  the  gonococcus  in  the  secretion  of  recent 
chronic  prostatitis,  and  never  in  that  of  long  standing. 
In  such  cases  the  micro-organism  most  frequently  present 
is  the  staph34ococcus.  In  case  of  doubt  whether  the  fluid 
examined  is  really  prostatic  secretion  or  not,  the  de- 
monstration of  the  sperm  crystals  will  be  conclusive  of  its 
prostatic  origin. 

If  the  urethra  is  examined  with  the  endoscope  the 
mucous  membrane  of  the  prostatic  portion  will  be 
found  to  be  swollen  and  hyperasmic.  The  verumontanum 
is  seen  to  be  especially  swollen,  and  projects  into  the 
lumen  of  the  endoscopic  tube  as  a  large  red  globular  body, 
bleeding  at  the  slightest  touch. 

Treatment. — The  treatment  for  chronic  prostatitis  is 
the  same  as  that  for  chronic  posterior  urethritis,  with 
certain  additional  measures.  First  and  foremost  is  the 
systematic  and  gentle  massage  of  the  prostate  twice  or 
thrice  a  week.  An  effect  of  the  massage  is  to  express  the 
contents  of  the  distended  prostatic  glands  and  ducts  into 
the  urethra,  and  so  to  permit  the  astringent  fluids  after- 
wards used  to  come  directly  into  contact  with  the  inflamed 
parts.  In  addition  to  unloading  the  over-distended  ducts 
and  mucous  glands,  the  massage  promotes  the  absorption 
of  the  inflammator}'  oedema  and  stimulates  the  muscular 
fibre  of  the  prostate. 


1  20     Treatment  of  Gonorrhoea  in  the  Male 

l-'ollowing  tlie  massage,  injections  or  instillations  of 
astringent  lotions  are  to  be  given.  As  long  as  bacteria 
are  present  injections  of  protargol  or  permanganate  of 
potash  are  indicated.  These  are  to  be  replaced,  as  the 
micro-organisms  disappear,  by  the  more  astringent  solutions 
of  nitrate  of  silver  and  sulphate  of  copper.  Care  must  be 
taken  that  the  massage  be  gently  performed,  as  sometimes 
the  gland  is  very  sensitive ;  and  should  signs  of  irritation 
follow,  its  use  must  be  suspended  for  a  time.  77;/.s'  iiiassaf^c 
of  the  }^'laiid  folknced  by  astringent  applications  is  the  cardinal 
treatment  for  chronic  prostatitis.  There  are,  however, 
certain  subsidiary  measures  which  may  be  employed 
with  advantage,  such  as  the  use  of  small  rectal  injections 
of  iodide  of  potassium,  the  internal  administration  of 
ergot,  and  the  employment  of  ichthyol  in  the  form  of 
suppositories. 

Under  this  treatment  the  urinary  threads  will  be  found 
slowly  but  steadily  to  diminish,  both  in  number  and  in 
size,  and  on  microscopic  examination  the  pus  cells  will 
be  seen  gradually  to  disappear. 

Throughout  the  treatment  of  chronic  prostatitis  careful 
attention  should  be  paid  to  the  patient's  general  health. 
Tonics,  change  of  air,  sea-bathing,  and  hydropathic  treat- 
ment in  general  are  valuable  means  of  not  only  improving 
the  tone  of  the  body,  but  of  diverting  the  mind,  and  so 
relieving  the  great  depression. 

After  the  treatment  recommended  has  been  pursued  for 
several  weeks  it  will  be  found  in  a  large  proportion  of 
cases  that  all  the  pus  cells  have  disappeared,  and  that  the 
prostatic  fluid  has  assumed  its  normal  character.  Yet  it 
cannot  be  denied  that  in  a  not  inconsiderable  number  of 
cases,  in  spite  of  the  most  prolonged  and  careful  treatment, 
a  few  pus  cells  may  occasionally  be  seen.  But  as  there  is 
evidence  to  show  that  the  occasional  presence  of  a  few  of 


Prostatitis  i  2 1 

these  cells  in  tlio  prostatic  sccretif;n  is  nrjt  of  /^aavc  conse- 
quence, I  believe  we  shall  be  studyin|^'  the  best  interests 
of  our  patient  if  we  content  ourselves  with  this  apparently 
imperfect  result,  rather  than,  by  too  prolon.j^ed  local  treat- 
ment, run  the  risks  of  converting  him  into  a  confirmed 
sexual  neurasthenic. 


cn.\rTi:K  iv 

SPERMATO-CYSTITIS 

Although  an  extension  of  the  i,'onorrhoeal  intlaniniation 
to  the  vesiculae  seminales  is  a  much  rarer  complication 
than  either  prostatitis  or  epididymitis,  it  certainly  occurs 
more  frequently  than  is  commonly  suspected.  In  the 
milder  forms  it  is  liable  to  be  entirely  overlooked,  and  in 
the  severe  cases  to  be  mistaken  for  prostatic  inflammation, 
especially  as  spermato-c}Stitis  is  generally  associated  with 
prostatitis.  Authorities  differ  greatly  in  their  estimate  of 
the  frequency  of  the  occurrence  (jf  this  complication. 
Columbini  puts  it  at  over  60  per  cent.,  whilst  Petersen 
(*  Verhandl.  d.  Deutsch.  dermatol.  Gesellsch.,'  IV.  Con- 
gress, 1894),  who  specially  examined  200  patients  on  this 
point,  places  it  as  low  as  4  per  cent. 

Clinically,  two  forms  of  the  disease  are  recognised — 
{a)  an  acute  inflammatory,  and  (b)  a  chronic  catarrhal 
spermato-cystitis. 

(a)  Acute  Spermato-Cystitis.  —  The  acute  form  may 
develop  at  any  period  in  the  course  of  a  posterior  urethritis, 
the  infection  spreading  along  the  ejaculatory  duct  to  the 
mucous  membrane  lining  the  seminal  vesicle.  An  acute 
catarrhal  inflammation  is  set  up,  and  the  vesicle  becomes 
distended  with  a  muco-purulent  secretion,  which,  under 
unfavourable  circumstances,  may  proceed  to  the  formation 


Spermato-Cystitis  123 

of  matter — empyema  of  the  vesicle,  which,  if  miopencfl, 
the  matter  may  burst  into  the  urethra,  rectum,  bhidder,  or, 
rarely,  into  the  peritoneal  cavity.  Generally,  however,  the 
catarrhal  condition  does  not  proceed  to  the  formation  of  an 
abscess,  but  either  resolves  completely  or,  more  frequently, 
passes  into  the  chronic  catarrhal  condition. 

Symptoms. — The  subjective  sym})toms  which  such  a 
condition  evolves,  though  exceedingly  distressing,  are 
rarely  sufficiently  distinctive  to  render  an  exact  diagnosis 
possible.  The  most  characteristic  symptom  is  the  frequent 
and  often  painful  emission  of  sanguineous  and  purulent 
seminal  fluid,  which  leaves  gray  spots  on  the  linen,  sur- 
rounded by  a  yellow  or  brown  ring. 

Apart  from  this,  the  symptoms  are  not  very  character- 
istic, and  are  common  to  acute  posterior  urethritis  and 
prostatic  abscess  —  viz.,  frequent  painful  micturition, 
accompanied  by  much  bladder  and  rectal  tenesmus,  and  a 
feeling  of  the  presence  of  a  foreign  body  in  the  rectum,  also 
by  increased  sexual  excitability,  accompanied  by  priapism 
and  the  above-mentioned  seminal  emissions.  Some  degree 
of  fever,  with  its  accompanying  general  disturbance,  is 
usually  present.  As  a  rule  only  one  vesicle  is  affected, 
and  the  infection  is  apt  to  spread  along  the  vas  deferens  and 
give  rise  to  a  concomitant  epididymitis.  On  examination 
per  rectum,  a  tender,  fluctuating,  sausage-like  swelling  can 
be  felt  above  the  prostate  in  the  situation  of  the  vesicle. 
Pressure  on  the  swelling  expresses  per  urethram  a  mixture 
of  pus  and  semen,  which,  when  microscopically  examined, 
shows  the  presence  of  spermatozoa,  leucocytes,  and  gono- 
cocci,  and  often  other  septic  organisms.  On  this  examina- 
tion the  diagnosis  of  acute  spermato-cystitis  rests. 

(6)  Chronic  Catarrhal  Spermato  -  Cystitis.  —  Here 
again  it  is  hardly  ever  possible  to  diagnose  the  condition 
from  the  subjective  symptoms  alone,  as  they  are  merely 


1 24     Treatment  of  Gonorrhoea  in  the  Male 

those  of  chronic  posterior  urethritis.  Xor  does  a  simple 
digital  examination  of  the  rectum  afford  much  help,  as  the 
vesicuhe  are  seldom  markedly  indurated  or  enlarged.  The 
diagnosis  is  made  or  excluded  by  the  careful  microscopic 
examination  of  the  expressed  contents  of  the  vesicula;. 
To  obtain  this  free  from  prostatic  and  urethral  contamina- 
tion, the  prostate  is  first  massaged,  and  the  patient  then 
empties  the  bladder,  so  as  to  renio\e  the  secretion  ex- 
pressed from  the  prostate  and  any  that  may  be  present  in 
the  urethra.  The  contents  of  the  vesicula;  are  now 
squeezed  out  either  by  means  of  the  finger,  or,  better, 
by  Feleki's  masseur  (p.  78).  The  expressed  contents, 
more  especiall_\-  the  sago-like  globulin  bodies,  are  then 
microscopically  examined  for  pus  cells  and  gonococci. 

Treatment.  —  The  treatment  of  spermato  -  cystitis, 
whether  in  the  acute  or  chronic  condition,  is  almost 
identical  \\ith  that  of  prostatitis  in  the  corresponding 
stage.  Thus,  the  acute  condition  is  treated  by  rest  in  bed, 
light  diet,  and  gentle  purgation.  The  urine  is  kept  acid 
and  antiseptic  by  the  internal  administration  of  such 
drugs  as  salicylate  of  soda  or  salol.  The  painful  bladder 
and  rectal  tenesmus  is  relieved  by  hot-water  enemata  and 
sitz-baths,  and  by  the  use  of  belladonna  suppositories. 
Should  an  abscess  form,  it  must  be  freely  opened,  pre- 
ferably from  the  perinaeum,  by  a  para-rcctal  incision. 

In  the  subacute  and  chronic  stages,  the  massage  of  the 
vesicula;  and  prostate  two  or  three  times  a  week  is  indi- 
cated, to  be  followed  by  urethral  irrigation  with  mild 
antiseptic  and  astringent  solutions.  Later,  iodide  of 
potassium  or  ichthyol  suppositories  may  be  used  to 
promote  absorption  of  the  inflammatory  induration. 


CHAPTER  V 

CYSTITIS 

OuK  views  on  cystitis  have  undergone  considerable 
modifications  during  the  last  few  years.  We  have  now 
learnt  that  many  of  the  cases  which  were  formerly  de- 
scribed as  cystitis  were  incorrectly  so  termed,  for  the 
chief  seat  of  the  inflammation  has  been  found  to  be  the 
membranous  and  prostatic  portions  of  the  urethra,  and  not 
the  bladder  as  was  then  thought.  It  is  not  surprising 
that  this  mistake  was,  and  is  still,  frequently  made,  for,  as 
we  shall  see,  the  subjective  symptoms  of  both  posterior 
urethritis  and  cystitis  are  very  similar.  And,  moreover, 
it  must  be  remembered  that  when  the  posterior  urethra  is 
affected,  the  inflammation  does  not  usually  stop  abruptly 
at  the  internal  vesical  sphincter,  but  also  to  a  slight 
extent  affects  the  lowest  portion  or  so-called  neck  of  the 
bladder.  For  this  reason  I  do  not  think  it  wase  to  attempt, 
as  several  writers  have  done,  to  distinguish  those  cases  of 
posterior  urethritis  in  which  the  neck  of  the  bladder  is 
also  involved  as  a  separate  class  under  the  term  '  urethro- 
cystitis '  or  '  cystite  du  col.' 

Posterior  urethritis  has  already  been  fully  discussed,  so 
it  is  here  unnecessary  to  say  more  on  that  subject  than 
that  it  has  been  ascertained  to  be  by  far  the  most  common 
of  all  the  complications  of  urethritis.     It  now  remains  for 

125 


i2t)     Treatment  of  Gonorrhoea  in  the  Male 

us  to  consider  that  form  of  iiiHaniniation  in  wliich  the 
whole  or  greater  part  of  the  inucous  membrane  of  the 
bladder  is  involved — true  C3-stitis.  Until  recent  years, 
this  had  always  been  regarded  as  one  of  the  most  common 
complications  of  urethritis.  But  as  more  exact  methods 
of  examination  have  enabled  us  to  distinguish  between  a 
true  cystitis  and  a  urethro-cystitis  or  posterior  urethritis,  we 
hnd  that,  while  the  latter  is  very  common,  the  former  is 
comparatively  rare,  and  that  while  cystitis  is  not  a  very 
frequent  complication  of  urethritis,  yet,  when  cystitis  is 
found,  it  is  most  frequently  attributable  to  urethritis. 
Indeed,  it  is  hardly  an  exaggeration  to  say  that  an  acute 
inflammation  of  the  bladder  occurring  in  a  young  or 
middle-aged  man  is  almost  invariably  a  direct  or  remote 
consequence  of  a  pre-existing  urethritis.  Cystitis  may 
arise  in  all  stages  of  the  disease,  both  the  acute  and  the 
chronic.  When  it  occurs  during  an  acute  attack  it  usually 
does  so  by  direct  extension  from  the  posterior  urethra  in 
the  third  or  fourth  week.  An  earlier  onset  is  generally 
due  to  a  direct  inoculation  of  the  bladder,  in  consequence 
of  instrumental  manipulation.  When  cystitis  arises  in 
the  chronic  stage,  it  may  develop  during  one  of  the 
frequent  exacerbations  of  the  urethritis  which  are  so 
common  a  feature  of  the  disease,  or  it  may  be  an  effect 
of  a  stricture  of  the  urethra.  Although  the  bladder 
becomes  inflamed  in  consequence  of  direct  extension  of 
the  urethral  inflammation,  it  is  comparatively  of  rare 
occurrence  that  the  infection  is  a  pure  gonococcal  one. 
Far  more  frequently  it  is  a  mixed  infection,  in  which  the 
bacterium  coli  or  staph}lococcus  predominates. 

Pathology.— The  first  effect  of  an  infection  of  the 
bladder  is  to  produce  a  general  hyperaemia  and  swelling 
of  the  mucous  membrane,  especially  in  the  region  of  the 
trigonum.     Should  the  infection  be  severe,  this  is  followed 


Cystitis  127 

by  a  free  desquamation  of  the  epithelium  and  the  migra- 
tion of  leucocytes.  The  urine  becomes  cloudy  from  the 
presence  of  mucus,  pus,  and  epithelial  cells,  in  addition  to 
the  phosphatic  salts.  As  the  inflammation  proceeds  the 
mucous  membrane  acquires  a  slate-gray  or  brownish-red 
colour  ;  it  is  swollen  and  infiltrated  with  leucocytes. 
Larger  or  smaller  abscesses  may  then  develop  in  the 
bladder  walls,  and  ulcers  appear  on  the  surface  of  the 
mucous  membrane.  In  the  severest  types,  more  or  less 
extensive  sloughing  of  the  mucus  and  even  of  the  muscular 
coats  may  take  place. 

Symptoms. — The  cystitis  which  arises  as  a  complica- 
tion of  gonorrhoea  rarely  affects  the  whole  of  the  bladder, 
but  is  usually  confined  to  the  lower  portion,  about  the 
internal  urethral  orifice  and  trigonum,  and  is  almost 
invariably  associated  with  a  coexisting  inflammation  of 
the  posterior  urethra.  Consequently,  its  subjective 
symptoms  are  practically  indistinguishable  from  those  of 
posterior  urethritis,  such  being  frequent  and  painful 
micturition,  with  severe  vesical  tenesmus,  and  shooting 
or  dull,  aching  pain  above  the  pubes,  in  the  perinaeum 
and  rectum.  The  patient  feels  himself  to  be  seriously  ill, 
is  slightly  feverish,  and  unable  to  sleep  on  account  of  the 
urinary  distress.  The  urine,  which  may  be  either  acid  or 
alkaline,  is  turbid,  contains  pus  and  epithelial  cells  and 
much  mucus,  and  occasional^,  towards  the  end  of  mic- 
turition, a  little  blood. 

The  differential  diagnosis  between  cystitis  and  posterior 
urethritis  is  based  principally  upon  the  character  of  the 
urme.  The  following  are  the  chief  points  of  distinc- 
tion :  In  cystitis  the  second  portion  of  urine  is  not  onl}' 
markedly  turbid,  but  is  constantly  so.  That  is  to  say, 
however  frequently  it  is  evacuated,  the  last  portion  passed 
is  always  more  cloudy  than  the  first.     In  posterior  ureth- 


128     Treatment  of  Gonorrhoea  in  the  Male 

litis  the  turbidity  is  neither  so  marked  nor  h\-  any 
means  so  constant.  Again,  if  we  make  use  of  Jadassohn's 
three-glass  test,  it  will  generally  be  found  in  cases  of 
cystitis  that  the  urine  in  the  third  glass  is  more  turbid 
than  in  the  second,  whilst  in  a  simple  posterior  ureth- 
ritis the  turbidity  in  the  second  and  third  glasses  is  the 
same.  The  reason  for  this  difference  lies  in  the  fact  that 
in  cystitis  the  pus  sinks  to  the  bottom  of  the  bladder,  and 
is  eyacuated  with  the  last  portion  <if  urine.  Although  this 
test  is  of  some  value,  an  undue  importance  must  not  be 
attached  to  it,  for  it  is  obvious  that  if  the  amount  of  pus 
secreted  in  the  bladder  be  slight,  it  will  not  collect  to 
any  appreciable  degree.  Moreover,  should  a  consider- 
able quantity  of  pus  be  regurgitated  from  the  posterior 
urethra,  it  will  make  its  way  to  the  base  of  the  bladder, 
and  so  simulate  a  cystitis.  A  more  important  diagnostic 
point  is  the  fact  that  the  jnis  from  a  cystitis  generally 
shows  large  numbers  of  desfjuamated  cells  of  the  l)ladcler 
epithelium. 

Under  suitable  treatment  the  acute  symptoms  generally 
disappear  in  from  seven  to  ten  days,  and  the  inflammation 
dies  down,  though,  like  most  of  these  complications,  it  is 
very  apt  to  relapse  again  on  the  slightest  provocation, 
and  not  infrequently  to  settle  into  the  chronic  condition. 
Hence  the  prognosis  is  alwa}s  grave,  for  though  cystitis 
is  only  rarely  directly  fatal,  yet  it  often  leads  to  an  in- 
veterate chronic  inflammation,  with  possibilities  of  still 
further  extension  to  the  ureters  and  kidneys. 

Treatment. — In  the  acute  stage,  when  pain  and  urinary 
distress  are  the  chief  features,  the  treatment  is  identical 
with  that  of  acute  posterior  urethritis,  to  which  section 
the  reader  is  referred.  Briefly  stated,  the  treatment 
consists  in  rest  in  bed,  light  diet,  gentle  purging,  and 
frequent  hot  sit/:-baths.      Salicylate  of  soda  or  salol  are 


Cystitis  129 

generally  the  most  useful  icmcdiis,  llioii};li  lln:  hnlsams 
and  urotropine  are  often  valuable,  mfjrc  (;s];ecially  in  tlie 
chronic  condition.  l''or  the  relief  of  the  pain  and  tenes- 
mus, belladonna  suppositories  are  perhaps  most  effi- 
cacious. Morphia  should  be  given  with  reluctance.  As 
long  as  the  acute  symptoms  last,  all  Irjcal  treatment  of 
urethra  and  bladder  should  be  suspended.  Later,  when 
the  pain  and  distressing  symptoms  have  disappeared, 
gentle  irrigation  of  the  bladder  and  urethra  may  be 
started.  For  this  purpose,  bland,  unirritating  solutions 
should  be  selected  at  first,  such  as  sulphate  of  thallin 
(I  per  cent.)  or  boracic  acid  (2  per  cent.).  If  this  is  well 
tolerated  it  may  be  changed  later  for  a  solution  of  one  of 
the  organic  silver  compounds,  such  as  protargol  (i  per 
cent.).  In  the  chronic  stages  of  the  disease  stronger 
solutions  may  be  employed  with  advantage,  especially 
those  of  silver  nitrate.  A  detailed  consideration  of  the 
treatment  of  chronic  cystitis  would  be  out  of  place  here, 
as  it  offers  no  special  features,  and  is  fully  described  in  the 
works  on  general  surgery. 


CHAPTER  \I 

PYELITIS  AND  PYELONEPHRITIS 

Etiology.  —  An  inllammation  of  the  pelvis  of  the 
kidney,  a  pyelitis  or  pyelonephritis,  arises  occasionally  in 
connection  with  urethritis,  both  in  its  acute  and  chronic 
stages.  Apart  from  the  rare  occurrence  of  a  metastatic 
deposit  in  the  kidney  tissues  through  the  blood,  the  in- 
fection is  brought  about  by  an  ascending  inflammation 
from  the  bladder,  by  means  of  the  ureter.  The  inflamma- 
tion spreads,  first  from  the  urethra  to  the  bladder,  and 
then  from  the  bladder  to  the  kidney.  In  the  large 
majority  of  such  cases  of  p}'elitis  it  will  be  found  that, 
in  addition  to  a  chronic  cystitis,  there  is  some  interference 
with  the  free  evacuation  of  the  urine  from  the  bladder, 
such  as  the  presence  of  a  stricture.  As  long  as  the  urine 
is  voided  freely  there  is  little  liability  of  an  inflammation 
spreading  from  the  bladder  along  the  ureters.  But  when, 
in  consequence  of  the  straining  occasioned  by  a  stricture 
or  some  other  cause,  an  increase  in  the  intravesical 
pressure  results,  it  leads  to  a  dilatation  of  the  ureters 
and  their  valve-like  openings  into  the  bladder,  and  so 
facilitates  the  spread  of  the  infection  along  the  ureters 
to  the  pelvis  and  kidney  proper,  thus  giving  rise  to  a 
pyelitis  or  pyelonephritis  (surgical  kidney).  The  infecticjn 
is  almost  always  a  mixed  one,  bacterium  coli  and  staphy- 

130 


Pyelitis  and  Pyelonephritis  1 3 1 

lococcus  prcdoriiiiKitin;;.  It  would  Im:  out  of  \)\:\(-ji  to  deal 
more  fully  with  this  condition  here,  as  it  helonpjs  to  the- 
domain  of  general  surgery. 

There  is,  however,  another  variety  of  kidney  infection 
in  connection  with  urethritis,  to  which  some  attention 
must  be  paid.  It  is  that  wliicli  arises  in  consequence  of 
the  spread  of  a  true  gonococcal  inflammation  along  the 
ureters.  Many  writers — amongst  others,  Finger — doubt 
that  this  ever  takes  place,  or  regard  it  as  the  rarest  of 
complications.  Others,  myself  included,  on  the  other 
hand,  believe  that  it  is  by  no  means  so  uncommon. 
There  is,  however,  often  great  difficulty  in  conclusively 
proving  its  existence.  The  subjective  symptoms  pro- 
voked by  such  an  infection  are  too  vague  and  insufficient 
to  be  of  any  great  diagnostic  \-alue.  The  most  marked 
of  them  is  the  complaint  of  a  dull,  aching  pain  in  the 
region  of  one  or  both  kidneys.  Less  characteristic  symp- 
toms are  the  presence  of  a  slight  degree  of  fever  (a  fairly 
constant  symptom),  increased  frequency  of  micturition, 
and  a  general  feeling  of  malaise,  with  an  occasional  initial 
rigor.  The  diagnosis  can  only  be  established  from  an 
examination  of  the  urine.  As  a  rule  it  is  either  acid  or 
neutral  in  reaction,  and  contains  more  or  less  pus.  If 
the  sediment  be  microscopically  examined,  there  may  be 
found,  in  addition  to  the  leucocytes  present,  either  renal 
epithelium  or  casts,  proving  conclusively  that  the  kidneys 
are  affected.  Again,  if  the  urine  be  tested  for  albumin, 
it  will  be  found  that  it  is  present  in  a  larger  quantity  than 
is  accounted  for  by  the  amount  of  pus  present.* 

*  To  determine  whether  the  albumin  corresponds  to  the  amount  of 
pus  present,  a  count  of  the  leucocytes  in  the  urine  may  be  made  by 
means  of  the  Thoma-Zeiss  apparatus.  Even  a  quantity  of  pus  in  the 
urine  shows  a  surprisingly  small  amount  of  albumin  :  80,000  to 
100,000  pus  cells  per  cubic  millimetre  only  gives  i  per  cent,  of 
albumin,  as  tested  by  Esbach's  method.     If,  for  instance,  the  urine  of 

9—2 


i;t2     Treatment  of  Gonorrhoea  in  the  Male 

It  is  necessary  here  to  sound  a  note  of  warning,  lest 
the  mere  presence  of  alhiiniin  in  the  urine  in  greater 
([uantity  than  can  be  accounted  for  by  the  amount  of  pus 
should  be  taken  in  itself  as  a  pathognomonic  sign  of 
nephritis.  It  is,  of  course,  nothing  of  the  kind.  It  is 
cjuitc  common  to  find  albuminuria,  pure  and  simple, 
in  patients  suffering  from  acute  posterior  urethritis  or 
cystitis,  independently  of  an}-  form  of  kidnej'  inllamma- 
tion.  The  exact  origin  of  this  albumin  is  doubtful.  It 
has  been  discussed  under  the  section  Posterior  Urethritis. 
It  will  also  be  remembered  that  the  urine  of  patients  who 
are  taking  large  doses  of  balsams  sometimes  becomes 
cloudy  when  treated  with  strong  mineral  acids,  and  thus 
simulates  the  presence  of  albumin.  This  turbidity  is  due 
to  precipitation  of  a  resinous  acid. 

Treatment. — Should  there  be  reason  to  think  that  an 
inflammation  was  spreading  up  the  ureters  to  the  kidneys, 
the  patient  should  be  treated  at  once  as  if  suffering  from 
acute  nephritis.  He  must  have  rest  in  bed,  light,  bland 
diet,  and  gentle  aperients.  For  medicine,  salicylate  of 
soda  or  salol  may  be  given  ;  the  balsams  are  too  irritating 
to  be  recommended.  In  the  chronic  forms  of  pyelitis 
the  chief  indication  is  in  the  thorough  treatment  of  the 
urethral  and  vesical  inflammation.  It  is  especially  im- 
portant to  remove  any  mechanical  obstacle  to  the  free 
evacuation  of  the  bladder. 


a  suspected  case,  containin.if  40,000  pus  cells  per  cubic  millimetre, 
yields  2  per  cent,  of  albumin,  it  is  clear  that  the  quantity  of  albumin 
in  the  urine  is  greater  than  can  be  accounted  for  by  the  amount  of  pus 
present,  and  its  origin  must  therefore  be  sought  for  elsewhere  O'osner, 
'  Diagnostik  der  Harnkrankheiten,'  III.  Auflage). 


CHAPTER  VII 
GONORRHCEA  RECTALIS— STOMATITIS  AND  RHINITIS 

The  mucous  membrane  of  the  rectum  is  occasionally 
the  seat  of  a  gonorrhoeal  inflammation.  It  is  far  more 
frequent  in  the  female  than  in  the  male,  in  whom  it  is 
decidedly  rare.  The  infection  may  be  conveyed  to  the 
bowel  in  several  ways.  Probably  the  most  frequent  cause 
is  a  lack  of  cleanliness  on  the  part  of  the  patient,  causing 
the  anal  mucous  membrane  to  become  grossly  con- 
taminated by  the  urethral  discharge.  For  obvious  reasons 
this  is  far  more  likely  to  occur  in  women  than  in  men.  A 
rarer  mode  of  infection  is  that  brought  about  by  the 
bursting  of  an  acute  prostatic  abscess  into  the  rectum. 
Lastly,  inoculation  may,  and  it  is  to  be  feared  frequently 
does,  take  place  through  coitus  per  anum. 

The  symptoms  generally  begin  by  a  sense  of  heat  and 
discomfort  about  the  anus  and  lower  part  of  the  bowel. 
This  discomfort  may  increase  in  severit}'  until  it  amounts 
to  actual  pain,  especially  on  defaecation.  The  anal 
mucous  membrane  becomes  swollen,  oedematous,  and  pro- 
lapsed, and,  at  a  later  period,  is  often  excoriated  and  deeply 
fissured.  The  inflammation  does  not  always  extend 
beyond  the  internal  sphincter  ;  but  should  it  do  so,  the 
rectal  mucous  membrane  becomes  swollen,  tender,  and 
covered  with  a  profuse  purulent,  and  often  blood-stained, 


134     Treatment  of  Gonorrhoea  in  the  Male 

discharge.  Although  there  seems  Httlc  or  no  tendency 
for  the  inflammation  to  extend  up  the  bowel  beyond  the 
rectal  portion,  there  is  a  liability  of  the  deeper  rectal  and 
perirectal  tissues  becoming  involved.  According  to 
Mikulicz,  this  at  a  late  and  often  remote  period  leads  to 
severe  cicatricial  contraction  and  stricture  of  the  rectum. 
An  examination  of  the  pus  in  the  acute  stage  shows  the 
presence  of  the  gonococci  in  large  numbers,  on  the 
finding  of  which  the  diagnosis  entirely  rests.  The  acute 
symptoms  soon  abate,  and  the  inflammation  disappears, 
but  not  infrequently  a  troublesome  chronic  rectal  catarrh 
persists. 

In  the  early  stages  the  treatment  consists  of  frequent 
cleansing  of  the  lower  part  of  the  bowel  with  warm 
mild  antiseptic  solutions,  such  as  boracic  acid,  protargol 
(2  per  cent.),  permanganate  of  potash  (i  in  5,000),  etc. 
The  pain  may  be  relieved  by  belladonna  suppositories  and 
frequent  hot  sitz-baths.  In  the  chronic  condition  strong 
astringent  injections  may  be  given,  more  especially  those 
of  nitrate  of  silver  and  sulphate  of  copper.  The  anal 
fissures  and  excoriations  are  best  treated  by  touching 
them  with  the  nitrate  of  silver  stick  and  the  use  of  a 
simple  ointment. 

Stomatitis  and  rhinitis  are  decidedly  rare,  though  they 
have  been  repeatedly  recorded.  They  have  been  found  in 
the  new-born  infant,  as  the  result  of  infection  by  the  vaginal 
secretion  during  parturition.  There  are  also  several  well- 
authenticated  cases  of  both  rhinitis  and  stomatitis  being 
met  with  in  the  adult.  I  have  recently  seen  a  gonorrhoeal 
stomatitis  in  a  barmaid.  In  this  case  the  mucous  mem- 
brane of  the  mouth  was  red,  swollen,  and  granular,  and, 
in  places,  superficially  ulcerated.  The  appearance  and 
symptoms  were  those  of  a  rather  severe  simple  stomatitis, 
but  a  bacteriological  examination  of  the  secretion  showed 


Gonorrhoea  Rectalis 


.■).■) 


the  i)rcscncc  of  the  gonococcus.  The  case  was  treated 
with  astringent  antiseptic  mouth-washes,  and  the  ulcera- 
tion was  painted  with  strong  nitrate  of  silver  solution  ; 
but  the  disease  proved  very  intractable,  and  before  com- 
plete recovery  I  lost  sight  of  the  patient. 


CHAPTICK  \III 

GONORRHCEAL  METASTASES 

Hitherto  we  ha\'e  considered  onh-  such  complications 
as  have  arisen  from  a  direct  extension  of  the  urethral 
inflammation.  It  is  now  necessary  to  turn  our  attention 
to  those  which  occasionally  develop  as  the  result  of  the 
gonococci  escaping  into  the  general  circulation  and  giving 
rise  to  a  form  of  septicemia,  with  metastatic  deposits. 
These  metastases  may  occur  at  almost  any  period  of  the 
disorder,  either  in  the  acute  or  chronic  condition.  Most 
frequently  they  are  met  with  in  about  the  third  week  of 
the  disease  —  that  is  to  say,  at  about  the  time  when 
posterior  urethritis  most  commonly  develops.  Personally, 
I  have  never  met  with  metastatic  trouble  in  the  male,  save 
when  the  posterior  urethra  was  also  involved,  though 
several  observers  have  recorded  its  development  not  only 
in  cases  of  anterior  urethritis,  but  even  in  ophthalmia 
neonatorum. 

Synovitis  (Gonorrhoea!  Rheumatism). 

The  commonest  place  for  such  metastatic  deposits  to 
occur  is  in  the  synovial  membrane  of  the  large  joints, 
where  it  gives  rise  to  an  acute  inflammation  of  that  joint, 
the  so-called  gonorrhceal  rheumatism.  The  association 
of  rheumatism  with  gonorrhoea  has  been  recognised   for 

136 


Gonorrhoeal  Metastases  ^Z1 

very  many  years,  tlioiij^^Ii  ikiI  iir.illy  its  Inu;  rclationshiij 
was  not  understood  until  the  gonococcus  had  been  dis- 
covered. It  would  serve  little  purpose  to  trace  the  various 
theories  and  conjectures  that  have  been  put  forward  as  to 
the  relationship  between  the  two  conditions.  It  is  now 
established  beyond  all  doubt  that  the  rheumatic  lesions 
are  due  to  the  gonococci  escaping  into  the  blood-stream 
and  lodging  in  the  synovial  membrane  of  the  joint,  and 
there  setting  up  a  more  or  less  acute  inflammation. 
Frequently,  though  not  always,  the  specific  cocci  may  be 
demonstrated  in  the  effused  fluid.  As  a  rule,  the  infection 
is  purely  gonococcal,  though  at  times  other  septic  organisms 
may  be  present,  more  especially  the  staphylococcus. 
This  rheumatic  complication  is  found  in  about  2  per  cent, 
of  all  cases  of  urethritis.  It  has  a  curious  and  marked 
tendency  to  affect  certain  joints  in  preference  to  others. 
This  is  well  shown  in  the  following  table,  drawn  up  b}- 
Finger  from  376  cases  recorded  b}'  various  observers  : 


Knee 

Ankle      ... 
Wrist 
Fingers  ... 
Elbow     ... 
Shoulder 
Hip 
Jaw- 
Other  joints 


136 
59 
43 
35 
25 
24 
18 

14 

22 


Unlike  true  rheumatism,  gonorrhoeal  rheumatism  attack= 
few  joints  at  the  same  time — as  a  rule,  onl}'  one  or  two. 

The  inflammation  develops  suddenly  in  most  cases ; 
the  joint,  which  was  apparently  perfectly  well  a  few  hours 
before,  suddenly  becomes  painful  and  swollen.  The 
disease  is,  however,  peculiarly  variable  in  its  course, 
sometimes  coming  on  suddenly,  and  at  others  by  slow 
degrees.  It  also  shows  a  tendency  to  vary  in  accordance 
with  the  condition  of  the  urethritis,  each  exacerbation  or 


i;>S     Treatment  of  Gonorrhoea  in  the  Male 

relapse  of  the  gonorrhcea  causing  an  increase  or  return  of 
the  synovitis.  So,  too,  if  the  rheumatism  develops  during 
an  acute  urethritis,  it  generally  is  also  acute,  the  joint 
rapidly  becoming  painful  and  swollen,  keeping  pace  with 
the  urethritis  and,  under  suitable  treatment,  disappearing 
with  it  in  six  or  eight  weeks.  On  the  other  hand,  should 
the  rheumatism  develop  in  the  course  of  a  chronic 
urethritis,  then  the  synovitis  runs  a  less  acute  course,  but 
disappears  more  slowly.  Both  forms  are  generally  accom- 
panied by  some  slight  fever,  though,  naturally,  in  the 
chronic  form  it  is  less  marked.  As  compared  with  true 
rheumatism,  the  fever  is  decidedly  less  marked  and  less 
persistent.  In  gonorrhoea!  rheumatism  the  joint  becomes 
distended  with  a  slightl}^  turbid  serous  exudation,  which 
under  unfavourable  conditions  may  become  purulent.  The 
skin  over  the  joint  is  rarely  reddened  or  oedematous. 
The  exudation  lluid  in  the  joint  undergoes  gradual  absorp- 
tion, though  occasionally  it  may  last  as  a  troublesome 
chronic  serous  exudation.  More  frequently  the  arthritis 
leads  to  a  partial  or  complete  ankylosis  of  the  joint.  A 
rare  and  grave  development  is  the  occurrence  of  suppura- 
tion;  such  cases  frequently  have  a  fatal  termination.  I 
have  seen  one  in  which  nearly  every  joint  in  the  body 
suppurated.  It  is  characteristic  of  this  form  of  rheuma- 
tism that  the  inflammation  does  not  wander  from  joint 
to  joint,  but  remains  in  that  which  is  first  affected, 
though  others  may  subsequently  become  inllamed.  Other 
gonorrhceal  inflammatory  troubles  not  infrefjucnth'  develop 
during  the  rheumatic  attack,  such  as  endocarditis,  iritis, 
and  cyclitis,  neuritis  (more  especially  in  tlic  form  of 
sciatica),  tenosynovitis,  and  myositis. 

ProgTiosis.^The  prognosis  is  in  general  good.  The 
effusion  into  the  joint  gradually  becomes  absorbed,  and  the 
joint  regains   its  free  movement.     Yet    it    should    be    re- 


Gonorrhoeal  Metastases  i39 

membered  tli;it  there;  is  the  pfxssihihty  of  some  stiffness  or 
ankylosis  following,  or  else  of  an  inccjmplete  disappearance 
of  the  lluid  and  a  chronic  hydrops  of  the  joint  persisting. 

Treatment. — The  treatment  calls  for  no  special  remark, 
other  than  that  it  should  be  on  jL^eneral  surgical  lines, 
as  in  any  other  acute  synovitis — rest  and  fixation  of  the 
joint  by  means  of  light,  well-padded  splints,  and  anodyne 
applications  to  relieve  the  pain  during  the  acute  stage. 
Later,  massage  and  gentle  pressure  to  the  joint  V)}'  means 
of  strapping  or  bandaging  are  useful  in  assisting  the 
complete  absorption  of  the  fluid  and  in  preventing  stiff- 
ness. Should  suppuration  take  place  the  joint  must  be 
freely  opened  and  drained.  The  urethritis  should  be 
treated  according  to  its  condition  at  the  time,  especial 
care  being  taken  to  avoid  provoking  an  exacerbation  by 
heroic  measures.  Internally,  salicylate  of  soda  or  salol 
should  be  given,  rather  for  its  beneficial  action  upon  the 
urethra  than  with  any  idea  of  specifically  influencing  the 
synovitis.  For,  unlike  true  rheumatism,  this  disease  does 
not  respond  to  the  salicines. 

Endocarditis. 

Next  to  the  joints  the  part  of  the  body  most  frequently 
affected  by  metastatic  infection  is  the  heart.  Although 
for  many  years  there  was  some  doubt  as  to  whether  these 
cases  were  directly  due  to  the  gonococcus,  this  has  now 
been  abundantly  proved  both  by  cultural  and  inoculation 
experiments.  Symptomatically  there  is  little  to  distinguish 
such  cases  of  endo-  or  peri-carditis  from  a  like  affection 
due  to  other  septic  organisms,  and  the  true  origin  of  the 
inflammation  can  only  be  inferred  from  its  onset  during  an 
attack  of  urethritis.  The  accuracy  of  this  diagnosis  can 
naturally  only  be  ascertained  b}'  a  bacteriological  examina- 


140     Treatment  of  Gonorrhoea  in  the  Male 

tion  after  death.  The  disease  seems  at  times  to  run  a 
mild,,  benij^jn  course,  and  at  others  a  deadly,  malignant 
one.  In  the  former  case  its  presence  may  only  be  in- 
dicated by  a  sudden  feeling  of  oppression  and  irregular 
and  distressing  action  of  the  heart,  accompanied  by  a 
slight  rise  of  temperature,  or,  perhaps,  by  a  rigor. 
Auscultation  may  reveal  a  soft  mitral  or  tricuspid  mur- 
mur. In  the  severer  cases  the  temperature  is  high  and 
rigors  are  frequent.  The  symptoms  increase  rapidly  in 
severity  and  lead  to  a  fatal  issue.  It  is  here  unnecessary 
to  discuss  the  subject  at  greater  length.  Recent  investiga- 
tions have  shown  that  metastatic  deposits  of  gonococci 
occur  occasionally  in  many  other  parts  of  the  body, 
giving  rise  to  various  forms  of  inflammation,  such  as 
pleurisy,  peritonitis,  meningitis,  iritis,  periostitis,  osteo- 
myelitis, cellulitis,  etc.  Such  inflammations  present  no 
characteristic  symptoms,  and  their  true  origin  can  only 
be  traced  by  careful  bacteriological  examination.  Lastly, 
there  are  certain  nervous  lesions  attributable  to  the  gono- 
coccus,  such  as  myelitis  and  peripheral  neuritis.  It  is  at 
present  uncertain  how  far  these  arc  due  to  metastatic  in- 
fection or  to  the  circulation  of  the  toxine  in  the  blood. 


PART  III. 

THE  PROOF  OF  THE  CURE  OF  GONORRHCEA  :  ITS 
BEARING  ON  MARRIAGE 

One  of  the  difficulties  in  the  treatment  of  this  disease 
arises  from  the  fact  that  the  patient  is  very  apt  to  regard 
himself  as  restored  long  before  a  cure  has  been  effected. 
As  soon  as  the  acute  symptoms  have  subsided,  and  the 
pain  and  copious  discharge  have  disappeared,  he  is  likely 
to  consider  his  complaint  to  have  passed  away,  or  at  any 
rate  to  be  no  longer  of  importance,  and  therefore  to  with- 
draw himself  from  further  treatment.  Such  a  procedure 
is  almost  certain  to  be  followed  by  a  relapse,  as  the 
gonococci,  not  being  entirely  eliminated  from  the  mucous 
membrane,  are  excited  to  greater  activity  by  the  patient's 
return  to  his  former  habits.  It  is  necessary  to  emphasize 
the  fact  that  the  cessation  of  the  discharge  is  no  proof  of 
the  cure  of  the  disease,  and  that  the  gonococci  may 
remain  in  some  portion  of  the  urethra  long  after  all 
apparent  signs  of  the  disorder  have  disappeared.  It  is 
therefore  of  much  importance  that  we  should  carefully 
consider  the  means  by  which  we  may  be  able  to  decide 
definitely  whether  a  cure  has  been  effected  or  not. 

Throughout  the  entire  course  of  the  disease  the  appear- 
ance and  character  of  the  urine  form  the  simplest  and 
best  indication  of  the  changes  which  are  taking  place  in 
the  urethral  mucous  membrane.     So  long  as  the  urine  is 

141 


14-     Treatment  of  Gonorrhoea  in  the  Male 

turbid  with  mucus,  and.  on  standing,  deposits  a  layer  of 
pus,  \\c  know  that  the  urethra  is  acutely  inflamed.  And 
this  may  be  cither  the  early  stage  of  a  recent  infection, 
or  an  acute  exacerbation  of  a  chronic  condition.  If  the 
urine  is  turbid,  but,  instead  of  depositing  pus,  shows  the 
presence  of  urethral  threads,  it  is  evident  that  the  inflam- 
mation has  passed  into  the  subacute  or  catarrhal  stage. 
And,  lastly,  the  presence  of  threads  floating  in  clear  urine 
denotes  the  chronic  localized  condition. 

Whilst  the  disease  is  in  the  acute  or  subacute  stage 
there  is  little  likelihood  of  either  doctor  or  patient  re- 
garding it  as  cured.  It  is  in  the  terminal  stage  alone  that 
the  difficulty  of  deciding  arises.  And  here  the  difficulty 
may  be  very  great,  and  the  decision  arrived  at  may  be  of 
much  moment  to  the  patient.  It  may  not  merely  involve 
the  question  as  to  whether  it  is  necessary  for  him  to  con- 
tinue the  treatment  or  not,  but  whether  he  is  entirely  free 
from  the  infection,  and  therefore  in  a  fit  state  for  marriage. 
During  the  last  few  years  the  attention  of  the  profession 
has  been  repeatedly  drawn  to  the  disastrous  effects  which 
gonorrhcea  has  upon  the  health  of  women.  Previously  it 
had  been  thought  that,  although  the  disease  frequently 
gave  rise  to  serious  complications  in  the  male,  it  was  but 
a  trivial,  local  malady  in  the  female.  We  now  know  that 
this  view  was  entirely  wrong,  and  we  have  learnt  to  regard 
the  disease  to  be  not  a  whit  less  serious  in  women  than  in 
men.  For,  so  far  from  the  inflammation  being  localized 
to  the  vulva  and  urethra,  it  frequently  spreads  insidiously 
to  the  uterus,  tubes,  ovaries,  and  peritoneum,  giving  rise 
to  grave  trouble  and  danger  in  the  form  of  endometritis, 
pyosalpinx,  perioophoritis,  and  pelvic  peritonitis.  It  is 
also  a  common  cause  of  abortion  and  sterility.  There  are 
few  pictures  sadder  than  that  which,  all  too  frequently, 
meets  the   surgeon's  eye  in  the   rapid  transformation   of 


The  Proof  of  the  Cure  of  Gonorrhoea      i  17, 

a  brij^'Iit,  healthy  f^irl  into  a  peevish,  chronic;  inv;i]i(J,  thf: 
consequence  of  a  gonon  lioj;il  infection  acf]uired  earl}'  in 
married  life. 

It  will  be  seen  at  once,  therefore,  to  be  of  the  utmost 
importance  that  we  should  be  able  to  determine  with 
certainty  whether  a  supposed  cure  is  actual  or  not,  and 
so  to  be  able  to  affirm  with  confidence  that  a  patient  who 
has  suffered  from  this  dire  disease  may  marry  without  fear 
of  infecting  his  wife.  In  order  to  do  this  effectually,  a 
most  careful  and  systematic  examination  of  the  patient  is 
necessary.  No  value  whatever  must  be  placed  on  his 
assertion,  however  confidently  made,  that  all  discharge 
has  completely  ceased,  and  that  there  is  nothing  to  be 
seen.  Apart  from  the  fact  that  he  will  naturally  take  the 
most  favourable  view  of  his  own  condition,  the  question 
cannot  be  determined  by  mere  casual  observation. 

The  first  point  to  be  decided  is  the  presence  or  absence 
of  the  gonococcus  in  the  urethral  secretion  or  in  the 
mucous  membrane.  So  long  as  the  coccus  is  present, 
there  can  be  no  question  as  to  the  patient's  infectious 
condition  and  his  requiring  further  treatment.  At  the 
same  time  it  must  be  noted  that  the  detection  of  the 
gonococcus  in  the  later  stages  of  urethritis  is  far  from  easy, 
and  that  it  demands  considerable  experience  and  patience. 
For  in  this  stage  the  micro-organism  is  present  in  very- 
sparing  numbers,  and  is  no  longer  found  in  its  character- 
istic situation  within  the  body  of  the  leucocyte,  as  in  the 
acute  stage.  Confusion  as  to  the  identity  of  the  organism 
is  under  such  circumstances  much  more  likeh*  to  occur 
than  in  the  earlier  stages  of  the  attack,  and  all  the 
resources  of  bacteriolog}'  may  have  to  be  invoked  to 
establish  the  diagnosis.  But,  further,  it  frequently 
happens  that  the  organism  is  absent  from  the  secretion 
for  days,  and  even   weeks,  together,   and   only   reappears 


144     Treatment  of  Gonorrhoea  in  the  Male 

when  the  urethra  is  unusually  stinuilatcd  Ironi  an)-  cause, 
such  as  sexual  excitement  or  indulgence  in  alcohol. 

In  the  intervals  the  micro-organisms  may  be  \y\ng,  perdu 
in  some  of  the  numerous  crypts  and  follicles  with  which 
the  urethra  abounds.  Hence,  when  attempting  to  decide 
whether  the  gonococcus  is  still  present  or  not,  it  is 
necessary  not  only  repcatcdh-  to  examine  the  secretion  at 
intervals,  but  also  to  take  such  steps  as  will  induce  a 
certain  stimulation  of  the  tract,  and  to  pay  special  atten- 
tion to  the  contents  of  the  seminal  vesicles  and  of  the 
prostatic  and  urethral  glands. 


Fig.  36. — Urethral  Thread  in  Chronic  Urethritis. 


It  may  be  convenient  here  to  discuss  the  details  of  such 
an  investigation.  The  iirst  step  is  to  examine  the  urine 
(preferably  that  passed  in  the  morning  on  rising)  for  any 
threads  or  deposit.  If  any  be  discovered  they  should  be 
stained  and  microscopically  examined.  At  this  stage  the 
threads  will  probably  be  found  to  consist  of  numerous 
epithelial  cells  and  a  few  pus  cells  held  together  by  mucin 
(Fig.  36).  Should  the  pus  cells  largely  predominate,  the 
probability  that  the  disease  is  cured  is  distinctly  small. 
If  no  gonococci  are  found,  all  treatment  should  be  sus- 
pended, and,  after  an   interval  of  a  few  days,  the   urine 


The  Proof  of  the  Cure  of  Gonorrhoea 


'45 


must  be  re-examined.  If  the  disease  is  not  cured  the 
stopping  of  the  treatment  will  probahly  l(;;i.d  to  an  infreasc 
in  the  number  of  the  threads  and,  possil)ly,  to  the  re- 
appearance of  the  micro-organism.  Should  no  gonococci 
be  found,  the  contents  of  the  seminal  vesicles  and  prostatic 
glands  should  be  expressed  by  massage  per  rectum,  and 
their  secretion  examined.  To  obtain  the  contents  of  the 
urethral  glands,  the  method  of  von  Crippa  is  usually 
employed.  A  large  acorn-headed  bougie  is  swept  up  and 
down  the  anterior  urethra,  whilst  the  surgeon  gently 
compresses  the  penis  between  the  flat  of  his  hand  and  the 
abdominal  wall  of  the  patient.  By  this  manoeuvre  the 
contents  of  the  crypts  and  follicles  are  expressed,  and 
appear  as  a  bead  of  secretion  at  the  meatus,  or  clinging 
to  the  head  of  the  bougie. 

The  next  step  in  the  examination  is  to  ascertain  if  the 
gonococci  reappear  after  stimulation  of  the  urethral 
mucous  membrane.  To  this  end  the  restrictions  which 
had  been  placed  upon  the  patient's  diet  may  be  removed, 
more  especially  as  regards  the  taking  of  alcohol,  and  he 
may  be  invited  to  drink  somewhat  freely  of  beer  or  wane 
on  one  day,  and  to  submit  himself  to  examination  on  the 
day  following  ;  or  the  urethra  may  be  irrigated  with  an 
irritating  lotion,  such  as  nitrate  of  silver  (i  in  2,000),  the 
day  before  the  examination.  Instead  of,  or  in  addition  to, 
the  irritating  injection,  the  urethra  may  be  dilated  by  the 
passage  of  a  large  bougie,  or,  better  still,  by  means  of  a 
dilator.  This  last  is  the  most  powerful  means  we  have  of 
bringing  any  hidden  focus  of  infection  to  the  surface,  for 
it  not  only  irritates  the  urethra,  but  squeezes  out  the 
contents  of  the  numerous  mucous  follicles,  in  the  depth  of 
which  the  gonococci  are  so  apt  to  lurk. 

A  new  method  of  bringing  any  hidden  gonococci  to  the 

10 


146     Treatment  of  Gonorrhoea  in  the  Male 

surface  has  recently  been  suggested  by  Alexander.*  It 
consists  in  the  injection  into  the  urethra  of  a  dilute  solu- 
tion of  peroxide  of  hydrogen.  As  soon  as  this  fluid  comes 
into  contact  with  blood,  pus  or  bacteria,  it  splits  up  into 
water  and  oxygen  under  strong  effervescence.  The  gas 
so  liberated  inechanicall}'  detaches  and  carries  away  any 
broken-down  epithelial  cells,  leucocytes,  and  bacteria 
which  may  be  present.  Alexander  claims  that  by  this 
means  gonococci  can  1)C  liberated  and  brought  out  of  their 
hiding-place  without  injury  or  irritation  to  the  mucous 
membrane,  and  that  it  avails  in  cases  where  all  the  usual 
methods  have  previously  failed.  For  this  purpose  he  uses 
Merk's  preparation  of  HoO.j,  which  contains  30  volumes 
by  weight  of  peroxide  of  hydrogen,  and  dilutes  it  with 
29  parts  of  water.  The  fluid  is  injected  and  allowed  to 
remain  for  about  a  minute  in  the  urethra.  The  foam 
which  then  exudes  from  the  meatus  is  collected  on  a 
glass  slide  and,  after  being  fixed  and  stained,  examined 
microscopically.  In  m}-  own,  at  present  limited,  ex- 
perience of  this  method,  I  have  found  it  simple  and 
efficacious  ;  but  it  is  yet  too  soon  for  me  to  attempt  to 
estimate  its  value  in  comparison  with  the  other  methods. 

//,  after  a  tlwruugh  and  repeated  e.xa)iiiuatiou,  no  'gono- 
cocci can  be  discovered,  are  we  justified,  ipso  facto,  in  declaring 
the  patient  to  be  no  longer  infectious,  and  in  giving  our  sanction 
to  his  marriage  ? 

On  this  point  there  is  a  difference  of  opinion  amongst 
the  various  authorities.  Some  f  would  confidently  answer 
the  above  question  in  the  affirmative,  on  the  ground  that 
the  only  criterion    of  the    infectiousness    of  a    urethritis 

*  '  Centralbl.   fiir  die  Krankheitcn  cier   Main  und  Sexual-Organe,' 
Bd.  16,  Heft  4,  1903. 
+  Neisser,  Jadassohn,  Sclioltz. 


The  Proof  of  the  Cure  of  Gonorrhoea      r47 

is  the  liiulinf;  (if  llu;  {^^onococcus.  Otlicr  ;uit horities,* 
however,  are  of  opinion  that  it  is  not  safe  tfj  rely  solely 
on  the  negative  evidence  of  the  bacteriological  examina- 
tion, no  matter  how  thoroughly  soever  it  may  have  been 
made.  They  contend  that  due  consideration  must  be 
given  to  other  factors,  such  as  the  character  of  the 
urinary  threads  and  the  appearance  of  the  mucous 
membrane,  as  seen  by  the  urethroscope.  They  hold, 
and  my  experience  entirely  confirms  this  view,  thai  as 
long  as  the  threads  are  largely  composed  of  pus  cells,  one 
is  justified  in  being  suspicious  that  the  gonococcus  still 
lurks  somewhere  in  the  urethra.  And  they  affirm  that 
before  the  surgeon  can  confidently  assert  that  the  patient 
is  no  longer  infectious,  not  only  must  the  gonococcus  be 
absent  from  the  secretion,  but  also  the  mucous  membrane 
must  have  regained  its  normal  bright  glistening  appear- 
ance ;  its  longitudinal  folds  must  be  clearly  defined,  and 
it  must  be  free  from  all  inflammatory  areas. 

Although  the  continued  presence  of  threads  containing 
pus  cells  is  rightly  to  be  considered  as  a  reason  for  regard- 
ing the  patient  with  suspicion,  yet  we  are  far  from  being 
warranted  in  assuming,  as  Levint  does,  that  the  gono- 
coccus is  therefore  necessarily  present.  For  such  threads 
may  be  produced  by  other  forms  of  urethritis  than  that 
arising  from  the  gonococcus. 

Should  the  microscopical  examination  show  that  the 
threads  consist  almost  wholly  of  epithelial  cells,  the  same 
importance  must  not  be  attached  to  their  appearance  in 
the  urine.  For  it  sometimes  happens  that,  long  after 
the  gonorrhoeal  inflammation  has  subsided,  such  threads 
are  passed,  and  are  merely  evidences  of  a  desquamative 

*  Oberlander,  Kollmann,  Wossidlo,  Levin. 

+  Levin,  '  Wann  konnen  wir  die  Gonorrhoea  als  geheilt  ansehen  ?' 
Arch.fiirDenn.  it.  Syp/i.,  Bd.  55.  s.  32. 

10 — 2 


14^*^     Treatment  of  Gonorrhoea  in  the  Male 

catarrhal    CDiKliiioii,    kept     up    b)-    i\\v    astrin,L;ciU    injec- 
tions. 

//  the  persistence  oj  threads  formed  of  pus  cells  is  a  sufficient 
reason  to  warrant  the  surgeon  in  hesitating  to  give  his  consent 
to  the  patient" s  marriage,  must  it  also  be  regarded  as  a  condition 
demanding  continuous  treatment  ? 

As  long  as  such  threads  are  passed,  it  is  certain  that 
some  part  of  the  urethra  is  still  inflamed,  and  the  patient 
cannot  be  regarded  as  in'  a  satisfactory  condition.  A 
determined  effort,  therefore,  should  be  made  to  ascertain 
the  exact  origin  of  the  threads,  and  to  cause  their  final 
disappearance.  But  in  treating  gonorrhcea,  as,  in  fact, 
all  diseases,  the  patient  must  be  considered  as  well  as  the 
disorder.  We  must  be  careful  lest  in  our  anxiety  to 
eradicate  the  last  vestige  of  inflammation  we  unduly 
prolong  the  treatment,  and,  by  centering  the  patient's 
thoughts  too  much  upon  his  trouble,  we  induce  serious 
neurasthenia  and  hypochondriasis. 

Notwithstanding  the  ver}'  considerable  advance  which 
has  been  made  in  the  treatment  of  gonorrhcea  during 
recent  years,  an  advance  which  enables  us  to  cure  an  ever- 
increasing  number  of  inveterate  cases,  it  must,  however, 
be  frankly  confessed  that  there  are  certain  cases  which  it 
is  not  in  our  power  thoroughly  to  cure — where  the  deeper 
structure  of  the  urethra,  and  more  especially  the  prostatic 
glands,  are  profoundly  affected,  and  where  in  spite  of 
persistent  and  appropriate  treatment  some  of  the  S}'mp- 
toms  still  persist.  In  such  cases  we  shall  only  do  harm 
by  remorselessly  continuing  the  treatment. 


INDEX 


AiiORTiVK    Ircatment    of    gnminlin'a. 

49.  SO 
.\bscess,  follicular,  104 
of  the  prostate,  114 
Acorn-headed  bougie,  79 
Adenitis,  106 
Albuminuria  in  posterior  urethritis,  21, 

22,  132 
Anatomy  of  the  urethra  and  bladder,  3 
Arthritis  gonorrhoica,  136-139 
Azoospermia  after  epididymitis,  no 

Bacteriuria,  26 
Balanitis,  99 

diagnosis  of,  100 

symptoms  of,  100 

treatment  of,  loi 
Bladder,  form  of,  7,  8 

inflammation  of,  125 

sphincters  of,  6 
Bladder-neck,  7,  12,  125 
'  Bon-jour  '  drop,  71 
Bougie,  acorn-headed,  79 

medicated,  92 

metal,  93 
Bubo,  106 

Calibre  of  the  urethra,  3,  8t 
Canals,  para-urethral,  loi,  102 
Caput    gallinaginis,    inflammation    of. 

69,  84,  85,  86 
Cavernitis  gonorrhoica,  104 
Central  figure  of  the  normal  urethra,  84 

in  chronic  urethritis,  86 
Charriere's  urethral  scale,  79,  80 
Chorda  venerea,  17 
Chordae,  17,  105 
Compressor   urethras  muscle,    function 

of,  12,  13,  23 
Copaiva  balsam,  43 
Cowper's  glands,  inflammation  of.  105 
Crystals,  sperm,  1 18 
Cystitis,  125 

diagnosis  of,  24,  25,  127,  128 
pathology  of,  126 


Cystitis,  prognosis  of,  128 
.symptoms  of,  127 
treatment  of,  128,  129 

Deferentitis,  108 
Diday's  method  of  irrigation,  61 
Dilatation    treatment    of   chronic    ure- 
thritis, 93 
Dilators,  urethral,  94 
Dittel's  bougie,  93 

Endocarditis  gonorrhoica,  139 
Endoscope,  81 

how  to  use,  83 

Schall's  (Fig.  21),  82 

simplest  form  of  (Fig.  20),  82 

Valentine's  (Fig.  22),  83 
Eosinophile  cells,  37 
Epididymitis,  107 

azoospermia  after,   no 

cause  of,  107 

diagnosis  of,  109 

prognosis  of,  no 

symptoms  of,  108 

treatment  of,  1 10 
Expectant   treatment    in    acute  gonor- 
rhoea, 50 

Feleki's  instrument  for  massage,  78 
Filaments  in  the  urine,  34,  35,  70,  71, 

72 
Five-glass  test  of  Kollmann,  24 
Folliculitis  urethralis,  104 

symptoms  of,  104 

treatment  of.   105 
Funiculitis,  108 

Gonococcus,  appearance  of,  29 
cultivation  of.  31 

detection  of.  in  acute  gonorrhoea, 
28 
in    chronic    gonorrhoea,     32, 

143 
discovery  by  Neisser,  2 
in  acute  gonorrhoea,  28 


149 


ISO 


Index 


(jonococcus  in  chronic  i^onorrlm  a,  32, 
76,  143 

niuUiplication  of,  30 

staining  of,  28    29 
by  Ciram,  30 
tionorrhrt-a.  bacterial  diagnosis  of,  27 

early  views  of,  I 

later  views  of,  2 

limits  to  treatment  of.  14S 

proof  of  cure  of,  141 

bearing  on  marriage,  146 

See  also  Uielhritis 
Ciram's  stain,  30 
Ciuyon's  l)ougies,  94 

instillation  syringe,  63 

I  lA-matuiia,  terminal,  21,  57 
ii-emospermia,  123 

Incubation  period  of  acute  gonorrhua, 

<5 

Infiltration,  urethral,  hard,  86 

soft,  86 
Instillation,  urethral,  62 
Internal  treatment  of  acute  gonorrhcea, 

of  chronic  gonorrhiea,  90 
Irrigation,  Diday's  method,  61 
Janet's  mdhixl,  59 
test,  25,  26 

Jadassohn's  three-glass  test,  24.  128 
Janet's  method  of  irrigation,  51) 
treatment  of  urethritis,  64 

Kidney,  inflammation  of,  131 
Kollmann's  dilators,  95 
five-glass  test,  24 

Lymphadenitis,  106 
Lymphangitis,  106 

Massage  of  prostate,  78,  117,  118,  119, 

120,  145 
Medicinal   treatment    of  acute    gonor- 
rhoea, 43 
of  chronic  gonorrho-a,  90 
Metastatic  inflammation,  136 
Micro-organisms  of  pseudo-gonorrhcta, 

28 
Microscopic     examination    in    pyelitis 
and  nephritis,  131 
in  spermato-cyslitis,  123 
of  prostatic  secretion,  77,  118 
of  urethral  secretion,  75,  143 
Micturition,  physiology  of,  10 

Neisser's  discovery  of  gonococcus,  2 
division  of  chronic  urethritis,  77 


Nephritis,  131 
Neurasthenia  sexualis,  73 

Oberlander's  dilators,  95 
Ockari's  syringe,  51 
Oligospermia  after  epididymitis.  1 10 
Orchitis.     See  Kpididymitis 

Papillomata,  102 

treatment  of,  103 
Paraphimosis,  100 
Para-urelhral  canals,  loi 
I'eri-urethral  inllammaiion  and  abscess, 

104 
Permanganate  nf  potassium   treaimenl. 

Janet's,  O4 
Phimosis,  100 

Phlegmony,  periprostatic,  114.  115 
Proctitis,  133 
Prophylactic  treatment   of  gonorrhcea, 

SO 
Prostatic  secretion,  normal.  118 
in  prostatitis,  77,  119 
sphincter,  6 
Prostatitis,  67,  114 
acute,  114 
chronic,  1 16 

symptoms  of,  117 
treatment  of,  1 19 
Prostatorrluea.  73 
Pseudo-gonorrh<ia,  28 
Pus,  acute  gonorrhnal,  29 
Pyelitis  and  pyelonephritis,  130 
etiology  of,   130 
treatment  of,  132 

Rectum,  inflammation  of,  133 
Relapses  in  gonorrhoa,  40 
Rheumatism,  gonorrho.al,  136 
Rhinitis,  134 

Secretion  in  acute  gonorrhcea,  34 
in  chronic  gonorrhcea,  75,  143 
in  prostatitis,  77,  1 18 
in  spermato-cystitis,  123 
.Seminal  vesicles,  inflammation  of,  122 
Sperniato-cystitis,  122 
acute,  122 

symptoms  of.  123 
treatment  of,  124 
chronic,  123 

treatment  of,  124 
.Sphincter  vesicae  externus,  6 

internus,  6 
Stomatitis,  134 
Stricture  of  urethra,  71 

of  wide  calibre,  79 
of  rectum,  134 
Suspensory  bandage,  112 


Index 


'5' 


Synovitis  (c;onorrli(i;al  rheumatism),  136 

l^iognosis  of,  138 

treatment  of,  139 
Syringe,  injection,  52 

large  uretliral,  91 

Ockart's,  51 

Tenesmus,  urinary,  in    acute  jxjslerior 
urethritis,  20,  57,  58 
in  chronic  posterior  urethritis, 

7i 
in  cystitis,  127,  129 
in  prostatitis,  1 15 
in  spermato-cystitis,  123 
Test,  five-glass  (Kollmanns),  24 
irrigation,  25.  26 

thre.e -glass  (Jadassohn's),  24,  128 
two-glass  (Thompson's),  22 
Thompson's,  Sir  H.,  two-glass  test,  22 
Threads,  urethral,  34,  35,  70,  71,  72 
Three-glass  test  of  Jadassohn,  24,  128 
Two-glass  test  of  Sir  H.  Thompson,  22 

Ultzmann's  instillation  syringe,  63 
Urethra,  anatomy  of,  3 

anterior  and  posterior,  5,  14 

and  bladder,  5,  7 

appearance  of.  during  healing,  87 
of,  when  chronically  inflamed, 

dilatation  of,  Qi, 
lumen  of,  3,  4 
membranous  portion  of,  84 
normal  prostatic,  85 
bulbous  portion  of,  85 
Urethral  irrigator,  Valentine's,  60 

mucous     membrane,    change     in, 
during  progress  of  disease,  37 


I  Jrel  hral  secretion,  appearance  in  earliest 
stage  of  gonorrhn-a,  35,  36 
morbid  changes  in,  34 
Urethritis,  signs  of  cure  of,  54,  55,  143 

acute,  15 
Urethritis,  pathology  of,    57 
treatment  of,  41-48 
anterior,  15 

exacerbation  of,  18 
symptoms  of,  16,  17 
treatment  of,  49 
])osterior,  19 

diagnosis  of,  22 
symjjtoms  of,  20 
treatment  of,  56-65 
to  determine  presence  of, 

25 
chronic,  66 

classification  <jf  forms  of,  69, 

89 
diagnosis  of,  74 
Neisser's  division  of,  77 
pathology  of,  68 
pus  of,  77 
symptoms  of,  70 
treatment  of,  89 
summary  of  treatment  of,  97 
See  also  Gonorrhciea 
Urethroscope,  use  of,  83 
Urethrocystitis,  125 
Urethrometer  described,  79 
Otis's,  80 
Kollmann's,  80 
Weir's,  80 

Valentine's  endoscope,  83 
urethral  irrigator,  60 
Vesiculitis.     See  Spermato-cystitis 


THE    END 


Baillierc,  Tindall  and  Cox,  8,  Henrietta  Street,  Covent  Garden,  London 


COLUMBIA   UNIVERSITY 

This  hook  is  due  on  the  date  indicnled  I>el<)\v,  oi-  al  tlie 
cxpinition  of  a  ilcfinite  period  after  the  date  of  borrow  iniLi, 
as  provided  l)y  the  rules  of  the  Ivibrary  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

c2a'e3aiMso 

L51 

RC202 


Leedham-Green 


